Istinye University Overview

Istinye University

• Founded in 2015 by the 21st Century Anatolian Foundation
• It is an extension of the MLPCare Group's 25 years of knowledge and experience
• MLPCare Group combines three hospital brands named "Liv Hospital”, “Medical Park " and "VM Medical Park"
• The university aims to be among the prominent universities in Turkey and the world
• It focuses on producing new knowledge through education and research
• It has a successful academic staff dedicated to education and research
• Provides a strong foundation for students in their fields by conveying existing knowledge
• Applies a student-centered education approach in all processes
• Aims to expand the boundaries of science with the research of its faculty members
• Aims to implement the findings obtained from scientific developments for the welfare of society
• Aims to provide high-quality and accessible healthcare services to the community
• Provides a learning and advancement environment that encompasses technology and art
• Conducts teaching, research, and community service activities at universal standards

General Survey, Vital Signs, and Pain Assessment

• Lecturer is Asst. Prof. Gizem Yağmur Yalçın
• Email is [email protected]
• Department is HSF /Nursing (English)

Outline

• The topics that will be contained in this discussion
• General Survey
• Vital Signs:
  • Temperature
  • Pulse
  • Respirations
  • Oxygen Saturation
  • Blood Pressure
  • Pain
• Pain Assessment

The General Survey

• Begins during the interviewing and history-taking process
• Healthcare professionals observe patients while collecting subjective data
• They develop initial impressions
• Formulate plans for collecting objective physical data
• Vital signs indicate the patient’s physiological status and response to their environment

Acute Assessment

• Indicators of an acute situation:
  • Extreme anxiety
  • Acute distress
  • Pallor
  • Cyanosis
  • Change in mental status
• In such cases, begin interventions while continuing assessment
• Obtain all vital signs and request assistance

Calling a Rapid Response Team

• A rapid response team may be called when the nurse senses something is wrong
• Symptoms include:
  • Respirations 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 - Equipment Needed

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

General Survey - First Component of Assessment

• Mental notes of the patient’s overall behavior, physical appearance, and mobility
• These help 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
• Behaviour
  • Facial Expressions
  • Level of Consciousness
  • Speech

Physical Appearance - Overall

• Note if the patient appears to be their stated age
• Check if the face and body are symmetrical
• Note any obvious deformities
• Note if the patient look well, ill, or distressed

Hygiene & Dress

• Observe clothes, hair, nails, and skin
• Is the clothing appropriate for age, gender, culture, and weather?
• Is the person clean and neat?
• Note any breath or body odors
• Check for the odor of alcohol or urine
• Is the skin clean and dry?
• Are nails and hair well kept and clean?
• Dress should be appropriate for age, gender, culture, and weather
• The patient should be clean and well-kempt
• Note whether any odors are present

Skin Color Assessment

• Observe skin tones and symmetry
• Note any redness, pallor, or cyanosis
• Observe lesions or variations in pigmentation
• Note the amount, texture, quality, and distribution of hair
• Skin should be even, with pigmentation appropriate to genetic background
• No obvious lesions or color variations observed
• Hair should be smooth, thick, and evenly distributed

Body Structure and Development

• Check if physical and sexual development is consistent with stated age
• Is the patient obese or not?
• Note the patient's height
• Are body parts symmetrical
• Check fingertips
• Note any joint abnormalities
• Physical and sexual development should be appropriate for age, culture, and gender
• No joint abnormalities should be noted

Behavior - Facial Expressions

• Assess the face for symmetry
• Note expressions while the patient is at rest and during speech
• Are movements symmetrical?
• Does the patient maintain eye contact appropriate to culture?
• Facial expression should be relaxed, symmetrical, and appropriate for the setting
• Note whether the patient maintains appropriate eye contact.

Behavior - Level of Consciousness

• Can the patient state their name, location, date, month, season, and time?
• Is the patient awake, alert, and oriented?
• Note agitation, lethargy, or inattentiveness
• The patient should be awake, alert, and oriented to person, place, and time
• They should attend and respond to questions

Behavior - Speech

• Listen to speech pattern
• How quick is it and is speech clear?
• Are the words appropriate?
• Does vocabulary and sentence structure offer clues to education?
• Assess for fluency in language and need for an interpreter
• The patient should respond quickly and easily
• Volume, pitch, rate, and word choice need to be appropriate
• Speech should be clear and articulate, flowing smoothly

Mobility - Posture

• Note how the patient sits and stands
• Is the patient sitting upright?
• When standing, is the body straight and aligned?
• Posture should be upright while sitting, with limbs and trunk proportional to body height
• The patient should stand erect with no signs of discomfort
• The arms should be relaxed at the sides

Mobility - Gait

• For the ambulatory patient, observe movements around the room
• Are they coordinated?
• Note any tremors or tics, as well as body parts that do not move
• Does the patient use assistive devices?
• Gait should be steady and balanced, with even heel-to-toe foot placement and smooth movements
• Other movements should be smooth, purposeful, effortless, and symmetrical

Anthropometric Measurements

• Height and weight
• Body mass index (BMI)

Vital Signs - General

• Reflect health status, cardiopulmonary function, and overall body function
• Check and establish a baseline
• Continue to monitor
• Evaluate the response to treatments
• Check for any risks
• Identify problems

Vital Signs Assessment

• Include: -Temperature -Pain -Pulse -Blood Pressure -Respirations -Oxygen Saturation

Vital Signs - Temperature - Normal Ranges

• Oral temperature ranges from 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

Vital Signs - Pulse

• Contraction of the heart causes blood to flow forward, which creates a pressure wave
• Heart rate for an adult is 60 to 100 beats/min (bpm)
• Apical pulse is usually assessed within a range of 60 to 100 beats/min and it is regular

Vital Signs - Respiration

• 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
• Respiratory rates for adults are 12 to 20 breaths/min and regular

Vital Signs - Oxygen Saturation

• Pulse oximetry is a noninvasive technique to measure oxygen saturation
• Oxygen saturation is the percent to which hemoglobin is filled with oxygen of arterial blood
• Pulse oximetry does not replace measurement of arterial blood gases for assessment of abnormalities
• It indicates abnormal gas exchange
• The finger is typically used to obtain a reading
• Pulse oximetry (SpO2) is typically 95% to 100 in people who are otherwise healthy

Vital Signs - Blood Pressure (BP)

• Measurement of the force performed by the flow of blood against the arterial walls
• These measurements change during contraction and relaxation of the heart
• Systolic blood pressure: the maximum pressure is performed on the arterial walls with contraction of the left ventricle at the start of systole
• Diastolic blood pressure: the lowest pressure occurs when the left ventricle relaxes between beats

Blood Pressure in Adults (mm Hg)

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

Vital Signs - Pain

• Pain is the fifth vital sign
• Key assessment data includes location, duration, severity, quality, and alleviating/aggravating factors
• Numeric pain intensity scale has 10 numbers: it ranges from 0 (no pain) to 10 (worst possible pain) to indicate pain severity
• The higher the number selected by the patient, the more severe the pain

Questions to Assess Pain - Location

• Assess "Where is the pain?", and try to have the patient point to area
• When there is more that one area of pain, have the patient rate each separately, and make note which is the most painful

Questions to Assess Pain - Duration

• Ask "When did you first become aware of the pain?"
• Ask "How long have you had this pain?"

Questions to Assess Pain - Intensity

• Ask:
  • 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 worse or better at different times of the day?
  • Does current pain medication decrease the intensity?

Questions to Assess Pain - Quality/Description

• Ask: "What does your pain feel like? Describe it in your own words."
• Also assess:
  • What makes the pain better?
  • What makes it worse?
  • What have you used to manage it?
  • Does applying heat make pain better or worse?
  • Does a cold pack help?
  • Does activity increase the pain?
  • Does sitting make it better?