İstinye University: General Survey & Pain Assessment

İstinye University

• Founded in 2015 by the 21st Century Anatolian Foundation.
• A continuation of the MLPCare Group's 25 years of knowledge, which combines the three hospital brands: "Liv Hospital", "Medical Park", and "VM Medical Park" under one roof.
• Aims to be among Turkey's and the world's leading universities by contributing to the production of new information with its education and research performance.
• The university provides an environment of learning and progress that encompasses technology and art, as well as a broad base of knowledge to students.
• The goal is to expand the boundaries of science through the research of faculty members, implement the findings obtained from scientific developments for the welfare of society, and provide quality and accessible health services to the public.

General Survey, Vital Signs, and Pain Assessment

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

Outline

• General Survey
• Vital Signs: Temperature, Pulse, Respirations, Oxygen Saturation, Blood Pressure, Pain
• Pain Assessment

The General Survey

• Begins during the interviewing and history process.
• 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’s physiological status and response to the environment.

Acute Assessment

• Indicators of an acute situation include extreme anxiety, acute distress, pallor, cyanosis, and changes in mental status.
• The nurse begins interventions while continuing the assessment.
• Vital signs are evaluated to determine rapid response team activation:
• Respirations less than 10 or greater than 32 breaths/min
• Increased effort to breathe.
• Oxygen saturation less than 92%
• Pulse less than 55 or greater than 120 beats/min
• Systolic BP less than 100 or greater than 170
• New onset of chest pain
• Agitation or restlessness
• All vital signs are obtained, and as needed help is requested.

Objective Data Collection

• Equipment needed include a scale, tape measure (for infants), height bar, stethoscope, pulse oximeter, watch with a second hand, and thermometer.

General Survey: First Component of Assessment

• Mental notes about the patient's overall behavior, physical appearance, and mobility help to form a global impression of the person.

General Survey Components

Physical Appearance

• Overall Appearance
• Hygiene and Dress
• Skin Color
• Body Structure and Development

Mobility

• Posture
• Range of Motion
• Gait

Behavior

• Facial Expressions
• Level of Consciousness
• Speech

Physical Appearance - Detailed Observations

Overall Appearance

• Assess if the patient appears to be the stated age, if the face and body are symmetrical, if there are any obvious deformities, and if the patient looks well, ill, or in distress.
• Facial features, movements, and body symmetry are typical.

Hygiene and Dress

• Observe clothes, hair, nails, and skin, noting appropriateness for age, gender, culture, and weather, cleanliness, and any breath or body odors.
• Dress is appropriate for age, gender, culture, and weather, with the patient clean and well-kempt and no odors noted.

Skin Color

• Observe skin tones and symmetry, noting any redness, pallor, or cyanosis, lesions, or variations in pigmentation, as well as hair amount, texture, quality, and distribution.
• Skin color is even, with pigmentation appropriate to genetic background, no obvious lesions or color variations, and hair is smooth, thick, and evenly distributed.

Body Structure and Development

• Consider overall physical and sexual development consistent with the patient's stated age.
• Look for obvious signs of joint abnormalities.

Behavior - Detailed Observations

Facial Expressions

• Assess the face for symmetry, noting expressions at rest and during speech. Determine if movements are symmetrical and if eye contact is appropriate to culture.
• Facial expression is relaxed, symmetrical, and appropriate for the setting and circumstances, with the patient maintaining appropriate eye contact.

Level of Consciousness

• Can the patient state their name, location, date, month, season, and time? Are they awake, alert, and oriented, and is there any agitation, lethargy, or inattentiveness?
• The patient is awake, alert, and oriented to person, place, and time, attending and responding to questions.

Speech

• Note the speech pattern, how quick it is, and speech clarity. Does the vocabulary and sentence structure provide clues to education? Assess speech fluency in language.
• The patient responds quickly and easily, and volume, pitch, rate, and word choice are appropriate, with speech clear, articulate, and flowing smoothly.

Mobility - Detailed Observations

Posture

• Note how the patient sits and stands. Determine if the patient is sitting upright and if the body is straight and aligned when standing.
• Posture is upright while sitting, with limbs and trunk proportional to body height. The patient stands erect with no signs of discomfort, with arms relaxed at the sides.

Range of Motion

• Can the patient move all limbs equally, and are there any limitations?
• Patient moves freely in the environment.

Gait

• For an ambulatory patient, note movements around the room and their coordination. Also, check for any tremors or tics, as well as body parts that do not move and if the patient uses assistive devices.
• Gait is steady and balanced, with even heel-to-toe foot placement and smooth movements. Other movements are smooth, purposeful, effortless, and symmetrical.

Anthropometric Measurements

• Height and weight
• Body mass index (BMI)

Vital Signs

• Reflect health status, cardiopulmonary function, and overall body function.

Vital Signs - Temperature

Oral temperature

• Normal Range: 35.8°C to 37.3°C

Axillary temperature

• Normal Range: 36.5°C or approximately 1°C lower than oral

Tympanic temperature

• Normal Range: 37.5°C or approximately equal to oral

Temporal temperature

• Normal Range: 37°C or approximately equal to oral

Rectal temperature

• Normal Range: 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.
• Heart rate for adults is 60 to 100 beats/min (bpm).
• Apical pulse typically ranges from 60 to 100 beats/min and is regular.

Respiration

• Respiration (breathing) supplies oxygen and eliminates carbon dioxide.
• Both inspiration and expiration occur discretely.
• Breaths are measured 30 seconds and multiplied by two to obtain breaths per minute.
• Normal adult respiratory rates range from 12 to 20 breaths/min and are regular.

Oxygen Saturation

• Pulse oximetry measures the percentage of hemoglobin filled with oxygen in arterial blood noninvasively.
• It does not replace measurement of arterial blood gases but indicates abnormal gas exchange.
• Typically, a finger is used to obtain the reading.
• Pulse oximetry (SpO2) ranges from 95% to 100% for healthy people.

Blood Pressure

• Measurement of the force performed by the flow of blood against the arterial walls, changing during contraction and relaxation of the heart.

Systolic Blood Pressure

• The maximum pressures performed on the arterial walls with contraction of the left ventricle at the start of systole.

Diastolic Blood Pressure

• Lowest pressure occurs when the left ventricle relaxes between beats.

Blood Pressure in Adults (mm Hg)

Pain

• The fifth vital sign that may indicate a health problem.
• Location, duration, severity, quality, and alleviating/aggravating factors are assessed.
• The numeric pain intensity scale rates pain from 0 (no pain) to 10 (worst possible pain) to indicate pain severity.
• The higher the number the patient selects, the more severe the pain.

Questions to Assess Symptoms

Location

• Where is the pain? Point to the painful area. (If more than one area hurts, have the patient rate each separately, and note which is most painful.)

Duration

• When did you first become aware of the pain? How long have you had it?

Intensity

• How much pain do you have on a 0 to 10 scale (0 being none and 10 is the worst you can imagine)?
• Is the pain worse or better at different times of the day?
• Does current pain medication decrease the intensity?

Questions to Assess Symptoms

Quality/Description

• What does your pain feel like?

Alleviating/Aggravating Factors

• What makes the pain better/worse?
• What have you used to manage it?
• Heat/cold applications?
• Does activity increase the pain?
• Does sitting make it better?