Istinye University & General Survey

İstinye University Overview

• Founded in 2015 by the 21st Century Anatolian Foundation, continuing the 25-year legacy of MLPCare Group, which united three hospital brands: Liv Hospital, Medical Park, and VM Medical Park.
• Aims to be among Turkey's and the world's distinguished universities.
• Provides a learning and advancement environment encompassing technology and art.
• Applies a student-centered education approach throughout the university.
• Aims to broaden the boundaries of science through faculty research and implement findings for the welfare of society.
• Provides high-quality and accessible healthcare services to the community.

General Survey

• The first component of assessment
• Initiated during the interviewing and history-taking process.
• Healthcare professionals observe patients, form initial impressions, and plan objective physical data collection while gathering subjective data.
• Vital signs are important indicators of a patient’s physiological status and their response to their environment.
• Mental notes regarding behavior, physical appearance and mobility can help form a global impression of the person.

Acute Assessment Indicators

• Characterized by extreme anxiety, acute distress, pallor, cyanosis, and changes in mental status.
• The nurse starts interventions while continuing the assessment.
• The nurse obtains all vital signs and seeks assistance.
• A rapid response team should be considered for respiration rates less than 10 or above 32 breaths/min.
• Increased effort to breathe indicates a need for rapid response.
• Oxygen saturation levels of less than 92% indicate a critical situation.
• A rapid response team should be considered for a pulse rate less than 55 or greater than 120 beats/min.
• Systolic blood pressure is less than 100 or greater than 170 may indicate an acute assessment scenario.
• Core body temperature is less than 35°C or greater than 39.5°C may require a rapid response.
• New-onset chest pain necessitates urgent attention.
• Agitation or restlessness may indicate the need to call a rapid response team.

Objective Data Collection Tools

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

Physical Appearance

• Factors include:
  • Overall appearance
  • Hygiene and Dress
  • Skin Color
  • Body Structure and Development
• Assess alignment and symmetry of the body and face.
• Note apparent state of wellness, illness or distress.
• Note clothes, hair, nails and skin.
• Consider the appropriateness of clothing for age, gender, culture, and weather.
• Assess if patient is well-kept and/or clean.
• Note presence of body odors, including alcohol or urine.
• Observe skin tone and symmetry, looking for redness, pallor or cyanosis.
• Look for lesions or variations in pigmentation.
• Note the amount, texture, quality, and distribution of hair.
• Assess if physical and sexual development are consistent with stated age.
• Identify obesity, height and body symmetry.
• Assess fingernails and look for joint abnormalities.

Behavior

• Factors include:
  • Facial Expressions
  • Level of Consciousness
  • Speech
• Check the face for symmetry. Note expressions during rest and speech.
• Ensure that movements are symmetrical. See if the patient maintains appropriate eye contact for their culture.
• Assess if the patient knows their name, location, date, month, season, and time.
• Determine if the patient is awake, alert, and oriented, and note any agitation, lethargy, or inattentiveness.
• Note the patient's responses to questions, ensuring they are awake, alert, and oriented to person, place, and time.
• Evaluate speech pattern, speed, and clarity.
• Consider the appropriateness of words and vocabulary. Evaluate fluency and need for an interpreter.
• Assess if speech is clear, articulate, and flowing smoothly, and ensure word choice, volume, and pitch are appropriate.

Mobility

• Factors include:
  • Posture
  • Range of Motion
  • Gait
• Note how the patient sits and stands, assessing if they are sitting upright and if their body is straight and aligned when standing.
• Look for erect posture, proportional limbs, and relaxed arms, and note discomfort.
• Note tremors or tics, and if the patient uses assistance devices.
• Note movements around the room, and if they are coordinated, steady and balanced.
• Assess gait by observing movements, heel-to-toe foot placement, and overall coordination.

Anthropometric Measurements

• Involve measuring height and weight to calculate body mass index (BMI).

Vital Signs

• Vital signs are key indicators of health status and overall body function.
• Factors include:
  • Temperature
  • Pulse
  • Respiration
  • Oxygen Saturation
  • Blood Pressure
  • Pain

Temperature Ranges

• Oral temperature: 35.8°C to 37.3°C
• Axillary temperature: 36.5°C or approximately 1°C lower than oral
• Tympanic temperature: 37.5°C or approximately equal to oral
• Temporal temperature: 37°C or approximately equal to oral
• Rectal temperature: 37.5°C or approximately 1°C warmer than oral

Pulse

• Contraction of the heart causes blood to flow forward, which creates a pressure wave known as a pulse.
• Normal heart rate for adults: 60 to 100 beats/min (bpm)
• Normal Apical pulse: 60 to 100 beats/min and regular

Respiration

• Respiration supplies oxygen to the body, and eliminates carbon dioxide.
• Inspiration and expiration should be discretely observed.
• Count for 30 seconds and multiply this by two to obtain breaths per minute.
• Normal respiratory rates for adults: 12 to 20 breaths/min and regular

Oxygen Saturation

• Pulse oximetry is a noninvasive technique to measure oxygen saturation as a percentage measurement of arterial blood.
• While it indicates abnormal gas exchange, it does not replace the measurement of arterial blood gases.
• Typically a finger is used to obtain a reading.
• Normal pulse oximetry (SpO2) is 95% to 100

Blood Pressure

• Blood pressure (BP) indicates the force of blood flow against arterial walls, which varies with contraction and relaxation of the heart.
• Systolic blood pressure refers to maximum pressure on arterial walls during ventricular contraction.
• Diastolic blood pressure is the lowest pressure when the left ventricle relaxes between beats.

Blood Pressure Ranges

• Hypotension: Systolic is less than 90, Diastolic is less than 60
• Normal: Systolic is less than 120, Diastolic is less than 80
• Prehypertension: Systolic is 120-139, Diastolic is 80-90
• Stage 1 Hypertension: Systolic is 140-159, Diastolic is 90-99
• Stage 2 Hypertension: Systolic is >160, Diastolic is >100

Pain

• Often referred to as the fifth vital sign
• Location, duration, severity, quality, alleviating and aggravating factors need to be assessed.
• Assess via a numeric pain intensity scale ranked from 0 (no pain) to 10 (worst possible pain) to indicate pain severity.
• The higher the number that the patient selects, the more severe is the pain.
• Questions that can assess symptoms of pain include:
  • "Where is the pain?" Have them point to the painful area.
  • If more than one area hurts, have the patient rate each pain and note which is most painful.
  • "When did you first become aware of the pain?" "How long have you had it?"
• How much pain do you have on a 0 to 10 scale (0 being none and 10 the worst you can imagine)?
  • "Is the pain better or worse at different times of the day?"
  • "Does current pain medication decrease the intensity?"
  • "What does your pain feel like? Describe it in your own words."
  • "What makes the pain better or worse?"
  • "What have you used to manage it?"
  • "Does applying heat or a cold pack help?"
  • "Does activity or sitting increase the pain?"