Istinye University: General Survey

Istinye University Overview

• Founded in 2015 by the 21st Century Anatolian Foundation
• It is backed by the 25 years of knowledge of the MLPCare Group, which unites three hospital brands: Liv Hospital, Medical Park, and VM Medical Park
• Aims to be among the top universities in Turkey and the world, by contributing to the creation of new knowledge
• Focuses on student-centered education and aims to be a science and research hub
• Strives to broaden the horizons of science through faculty research
• Aims to implement scientific findings for the welfare of society and provide quality, accessible healthcare services
• Committed to offering a learning environment that encompasses technology and art alongside a broad knowledge base

General Survey, Vital Signs, and Pain Assessment

• Lecturer: Asst. Prof. Gizem Yağmur Yalçın
• Email: [email protected]
• Department: HSF / Nursing (English)
• Lecture: NUR012-Health Assessment

General Survey

• The first component of assessment.
• Begins during the patient interviewing and history taking.
• Healthcare professionals observe patients, develop initial impressions, and formulate plans for collecting objective physical data while collecting subjective data
• Vital signs are important indicators of the patient Physiological status and response to the environment; this is why regular checking is important

Acute Assessment

• Indicators of an acute situation: Extreme anxiety, acute distress, pallor, cyanosis, and changes in mental status.
• In such cases, the nurse starts interventions while continuing assessment.
• The nurse should obtain all vital signs and request help.
• A rapid response team should be called if the situation requires it
• Acute symptoms may present themselves as:
  • Less than 10 or greater than 32 breaths/min
  • Increased effort to breathe is present
  • Oxygen Saturation is less than 92%
  • Either less that 55 bpm or greater than 120 bpm
  • Systolic BP is either less than 100 or greater than 170
  • Body Temp is less than 35°C or greater than 39.5°C
• New onset of chest pain
• Other indicators - Agitation or Restlessness
• These often indicate heart or respiratory issues

Objective Data Collection

• Equipment Needed:
  • Scale
  • Tape measure (for infants)
  • Height bar
  • Stethoscope
  • Pulse oximeter
  • Thermometer
  • Watch with second hand

Physical Appearance

• Includes overall appearance, hygiene and dress, skin color, and body structure and development
• Mental notes of the patient’s overall behavior, physical appearance, and mobility can help form a global impression of the person.
• Overall appearance:
  • Check symmetry
  • Note facial features
  • Facial Movements
• Hygiene and dress:
  • Note if clothing appropriate for patient age, gender, culture and weather
  • Patient is clean and well kempt
  • Note skin, hair, nails
  • No body odors

Skin Color

• Skin tones should appear symmetrical
• Note pallor, redness, or cyanosis
• Note lesions
• Look for variations in pigmentation
• Even skin tone
• Hair should be smooth thick and evenly distributed
• Body structure and development should be consistent with age, culture and gender
• Note Obese patients
• Are body parts symmetrical
• No joint abnormalities is expected

Behavior

• Includes facial expressions, level of consciousness, and speech
• Assess face for symmetry, symmetry of movement and whether expression is relaxed
• Appropriate eye contact
• Is patient oriented? (person place and time)
• Awake, alert and oriented
• Patient will attend and respond to the questions
• Speech should be clear and articulate

Mobility

• Includes posture and gait
• Can be used to assess speed of movement
• Note how the patient sits and stands
• Body Straight and Aligned
• Limbs proportional to body height
• Gait should be steady and balanced
• Movements should be smooth purposeful effortless and symmetrical

Anthropometric Measurements

• Height and weight
• Body mass index (BMI)

Vital Signs

• Reflect patient's overall health
• Monitor risks for alterations in health
• The following should be normal: temperature, pulse, respiration, oxygen saturation, blood pressure, and pain level

Temperature

• Taken orally, axillary, tympanic, temporal and rectally
• Normal temperature ranges are:
  • Oral: 35.8°C to 37.3°C
  • Axillary: 36.5°C or approximately 1°C lower than oral
  • Tympanic: 37.5°C or approximately equal to oral
  • Temporal: 37°C or approximately equal to oral
  • Rectal: 37.5°C or approximately 1°C warmer than oral

Pulse

• Adult heart rate is 60 to 100 bpm
• Contraction of the heart causes blood to flow forward, which creates a pulse.
• Apical pulse is 60 to 100 beats/min and regular.
• One also needs to check volume and rhythm of pulse

Respiration

• Adults breaths per minute is 12 to 20
• Respiration (breathing) supplies oxygen to the body and eliminates carbon dioxide.
• Observe both inspiration and expiration discretely
• Count for 30 seconds and multiply by two to obtain breaths per minute.

Oxygen Saturation

• Pulse oximetry is a noninvasive technique to measure oxygen saturation.
• An SpO2 of 95% to 100 for healthy subjects
• A finger is used to obtain a reading.
• Oximetry doesn't replace measuring arterial blood gases, but can be used to indicate abnormal gas exchange.

Blood Pressure

• Blood pressure is the measurement of the force performed by the flow of blood against the arterial walls.
• Varies durin contraction and relaxation of the heart
• Systolic blood pressure: Maximum pressure with contraction of the left ventricle.
• Diastolic Blood Pressure : Lowest pressure when the left ventricle relaxes in between beats
• According to systolic and diastolic pressures:
  • Hypotension- less than 90/ less than 60
  • Normal- less than 120/ less than 80
  • Prehypertension- 120-139/ 80-90
  • Stage 1 hypertension- 140-159/ 90-99
  • Stage 2 hypertension- more than 160/ more than 100

Pain Assessment

• Fifth vital sign
• Location, duration, severity, quality, alleviating/aggravating factors
• Use a numeric pain intensity scale so the subject may rate themselves from 0 to 10
• The higher the number that patient selects, the more severe the pain.
• Questions to assess symptoms include identifying point of origin, the duration, better or worse times of the day, what makes better or worse, how they manage, and whether they are taking any medication
• Quality: e.g Stabing, Cold, Tingling etc (described in patients own words)
• Is there any cold or heat that makes it better?