Istinye University: Health Assessment

İstinye University

• Founded in 2015 by the 21st Century Anatolian Foundation.
• It is backed by the MLPCare Group's 25 years of knowledge, uniting three separate hospital brands which include, "Liv Hospital", "Medical Park", and "VM Medical Park".
• Aims to be among Turkey's and the world's top universities by providing students with a strong foundation in their fields.
• Focuses on education and research, guiding students in their fields.
• Integrates student-centered education throughout all processes.
• Aims to broaden science, implement findings for societal welfare, and provide quality healthcare.
• Offers a learning environment encompassing technology and art, within universal standards of teaching, research, and community service.

General Survey, Vital Signs, and Pain Assessment

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

Outline

• Key areas covered include a general survey, vital signs, and pain assessment.
• Vital signs include temperature, pulse, respirations, oxygen saturation, blood pressure, and pain.

The General Survey

• The general survey starts during the patient interviewing and history taking.
• Healthcare professionals observe patients, form impressions, and plan for objective data collection.
• Vital signs indicate a patient's physiological status and response to their environment.

Acute Assessment

• Indicators include; extreme anxiety, acute distress, pallor, cyanosis, and altered mental status.
• Nurses intervene while continuing assessment.
• Nurses obtain all vital signs and request help when needed.
• A rapid response team may be called if a nurse senses something is wrong.
• Concerning vital signs:
• Respirations less than 10 or greater than 32 breaths/min.
• Increased effort needed 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.
• Temperature less than 35°C or greater than 39.5°C.
• New onset of chest pain.
• Agitation or restlessness.

Objective Data Collection

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

General Survey

• Is the initial part of assessment.
• Mental notes are taken of a patient's overall behavior, physical appearance, and mobility.
• It helps form a global impression of the patient.

General Survey Components

• Physical appearance encompasses overall appearance, hygiene/dress, skin color, and body structure/development.
• Mobility includes posture and gait.
• Behavior includes facial expressions, level of consciousness, and speech.

Physical Appearance Details

• Overall appearance factors in the patient's stated age, symmetry, deformities, and general state (well, ill, or in distress).
• Facial features, movements, and body symmetry should be observed.
• Hygiene and dress assessments include clothes, hair, nails, and skin, also noting breath or body odors.
• Patients attire should be appropriate for age, gender, culture, and weather.
• Skin color evaluation includes skin tones, symmetry, lesions, pigment variations, and hair distribution.
• Hair should be smooth, thick, and evenly distributed.
• Body structure and development assessment covers consistency with stated age, height, body part symmetry, and joint abnormalities.

Behavior Details

• Facial expressions should be assessed for symmetry, with expressions noted both during rest and speech.
• Assess if movements are symmetrical and note if eye contact appropriate to culture.
• Evaluate if patient is relaxed, symmetrical, and appropriate for setting and circumstances, and that the patient maintains appropriate eye contact.
• Level of consciousness is determined by the patient stating; name, location, date, month, season, and time and if they are awake, alert, and oriented, documenting and agitation, lethargy, or inattentiveness.
• When observing speech; vocabulary, sentence structure, fluency, language needs, and interpreter requirements should be assessed. Patients should respond and speak both quickly and easily. Volume, pitch, rate, and word choice need to be appropriate while the articulation should be clear and speech is flowing smoothly.

Mobility Details

• Posture and alignment are key observations when patients sit, stand, or lie in the environment.
• Posture is upright.
• Limbs and trunk are proportional to body height.
• Relaxed arms at the sides while showing no signs of discomfort.
• Gait should also be assessed, by observing movements, coordination, tremors, and assistive devices during the evaluation.
• Movement should be coordinated, balanced with steady and balanced heel-to-toe foot placement.
• Movements should be both balanced and symmetrical.

Anthropometric Measurements

• Height and weight should be measured during the assessment.
• Body mass index (BMI) should be determined.

Vital Signs

• They indicate overall health, cardiopulmonary function, and physical statues.
• Baseline establishment, condition monitoring, treatment response evaluation, problem identification, and health alteration risk monitoring are all important in this step.

Vital Signs to Monitor

• Temperature
• Pain
• Pulse
• Respirations
• Blood Pressure
• Oxygen Saturation

Vital Signs - Temperature

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

Vital Signs - Pulse

• Contraction of the heart forces blood forward, creating a pressure wave or pulse.
• Normal heart rate for an adult: 60 to 100 beats/min (bpm).
• A regular apical pulse should be 60 to 100 beats/min.

Vital Signs - Respiration

• Breathing supplies oxygen while eliminating carbon dioxide from the body.
• Inspiration and expiration must be observed discreetly.
• Breaths per minute calculation: count for 30 seconds and multiply by two.
• Respiratory rates for adults: 12 to 20 breaths/min and regular.

Vital Signs - Oxygen Saturation

• Pulse oximetry is a noninvasive technique for measuring oxygen saturation or the percentage of arterial blood hemoglobin.
• It indicates abnormal gas exchange and does not replace measurement of arterial blood gases for assessment of abnormalities.
• SpO2 of 95% to 100% is considered normal for healthy individuals.

Vital Signs - Blood Pressure

• Blood pressure (BP) is the force exerted by the flowing blood against arterial walls.
• It is directly affected by both the heart's contraction and relaxation.
• Systolic pressure is the maximum pressure exerted on the arterial walls.
• It occurs with contraction of the left ventricle at the start of systole.
• Diastolic pressure is the lowest pressure.
• It happens when the left ventricle is relaxing between beats.

Blood Pressure Measurements for Adults (mm Hg)

• Hypotension: Systolic <90 / Diastolic <60
• Normal: Systolic <120 and Diastolic <80
• Prehypertension: Systolic 120-139 or Diastolic 80-90
• Stage 1 hypertension: Systolic 140-159 or Diastolic 90-99
• Stage 2 hypertension: Systolic >160 or Diastolic >100

Vital Signs - Pain

• Pain is the fifth vital sign.
• Assessment includes location, duration, severity, quality, and alleviating/aggravating factors.
• A numeric pain intensity scale, ranked from 0 (no pain) to 10 (worst possible pain), should be included.
• The higher the number selected, the more severe the pain.

Pain Assessment Questions

• Location questions point to the painful area. Individual pain rates help show which is most painful.
• Duration questions include length of awareness of pain.
• Intensity needs to range from 0 to 10, from none to worst possible.
• Additional questions to ask; Is the pain worse or better at different times of the day and does medication decrease the level of pain?
• Evaluate the pain description including; descriptions of the pain in the patients own words, what makes the pain better, what makes it worse, and what do they use to manage the pain? What if they apply hear or cold packs? Does sitting or activity increase the pain?