Nursing: General Survey, Vital Signs, and Pain

Istinye University

• Founded in 2015 by the 21st Century Anatolian Foundation, continuing the 25-year legacy of the MLPCare Group.
• MLPCare Group united three hospital brands: Liv Hospital, Medical Park, and VM Medical Park.
• The university aims to be among the distinguished universities in Turkey and the world, and produce new knowledge.
• Istinye University aims to provide quality and accessible healthcare services to the community.

General Survey, Vital Signs, and Pain Assessment

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

Outline

• The general survey is the first component of assessment.
• Vital signs include temperature, pulse, respirations, oxygen saturation, blood pressure, and pain.
• Pain assessment is important.

General Survey

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

Acute Assessment

• Indicators include extreme anxiety, acute distress, pallor, cyanosis, and changes in mental status.
• The nurse begins interventions while continuing assessment.
• The nurse obtains all vital signs and requests help.
• A rapid response team may be called if something is going wrong or if the patient displays:
  • 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

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

General Survey Components

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

Physical Appearance Factors

• Overall appearance
• Hygiene and dress
• Skin color
• Body structure and development

Mobility Factors

• Posture
• Range of motion
• Gait

Behaviour Factors

• Facial expressions
• Level of consciousness
• Speech

Physical Appearance - Overall Appearance

• Assess if the patient appears the stated age
• Check if the face and body is symmetrical
• Note obvious deformities
• Assess if the patient looks, well, ill, is in distress

Physical Appearance - Hygiene and Dress

• Observe clothes, hair, nails, and skin
• Assess if the clothing is appropriate for age, gender, culture, and weather
• Check is clothes is clean and neat, and for breath or body odors
• Assess if the hair and nails are well-kept and clean

Physical Appearance - Skin Color

• Observe skin tones and symmetry
• Note any redness, pallor, or cyanosis
• Check for lesions or variations in pigmentation.
• Note the amount, texture, quality, and distribution of hair.

Physical Appearance - Body Structure and Development:

• Assess if physical and sexual development is consistent with stated age
• Determine if the patient is obese or not
• Measure how tall the patient is
• Assess if the body parts are symmetrical
• Note fingertips
• Check for any joint abnormalities

Behavior - Facial Expressions

• Assess the face for symmetry
• Note expressions while the patient is at rest and during speech.
• Assess if movements are symmetrical
• Assess if the patient maintains eye contact appropriate to culture

Behavior - Level of Consciousness

• Check if the patient can state name, location, date, month, season, and time
• Assess if the patient is awake, alert, and oriented.
• Note any agitation, lethargy, or inattentiveness.

Behavior - Speech

• Listen to the speech pattern
• Measure how quickly someone is speaking
• Check if speech is clear
• Assess if words are appropriate
• Note fluency in language and need for an interpreter

Mobility - Posture

• Note how the patient sits and stands.
• Assess if the patient is sitting upright.
• When standing, check if the body is straight and aligned.

Mobility - Range of Motion

• Assess if the patient can move all limbs equally
• Check for any limitations

Mobility - Gait

• For the ambulatory patient, observe movements around the room
• Check if movements are coordinated
• Note any tremors or tics, as well as body parts that do not move
• Determine if the patient uses assistive devices.

Anthropometric Measurements

• Height and weight
• Body mass index (BMI)

Vital Signs

• Reflect health status, cardiopulmonary function, and overall body function.
• Establish a baseline to monitor a patient's condition.
• Evaluate responses to treatment and identify problems by monitoring risks for alterations in health.

Vital Signs - Temperature Normal 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.
• Normal Heart rate for an adult: 60 to 100 beats/min (bpm)
• Apical pulse: 60 to 100 beats/min and regular

Respiration

• Supplies oxygen to the body and eliminates carbon dioxide.
• One should discretely observe both inspiration and expiration.
• Count for 30 seconds and multiply by two to obtain breaths per minute.
• Normal respiratory rates for adults: 12 to 20 breaths/min and regular

Oxygen Saturation (SpO2)

• SpO2 should be 95% to 100
• Pulse oximetry measures oxygen saturation, and indicates arterial blood filling with oxygen
• Use a noninvasive technique to measure noninvasively
• Can indicate abnormal gas exchange; replace measurement of arterial blood gases for assessment of abnormalities

Blood Pressure (BP)

• Blood flow against arterial wall measurement
• This changes alongside contraction and relaxation of the heart
• Systolic blood pressure is max measured pressure when the artery walls contract
• Diastolic blood pressure is measured by arterial walls with contraction of the left ventricle

Pain

• This is the fifth vital sign
• It is important for assessments
• Location, duration, severity, quality, and alleviating/aggravating factors should be determined
• The numeric pain intensity scale with 10 numbers ranks pain from 0 (no pain) to 10 (worst possible pain)
• The higher the number selected, the more severe is the pain.

Symptoms Assessment

• Location - Find where the pain is and how intense it is in different locations
• Duration - Find when the patients first has pain
• Intensity - How much pain you have on a 0 to 10 scale
• Determine if there pain medications decrease intensity

Questions to Assess Symptoms:

• Describe the quality/description of the pain
• Describe what your pain feels like in your own words
• Describe alleviating/aggravating factors, what makes the pain worse, managing, heat packs helping, cold packs helping, activity, and sitting