Assessment Week 2: General Survey, Vital Signs and Documentation

Objectives

• Understand vital signs, how to take them, and interpret results.
• Learn pain assessment techniques.
• Document findings effectively.
• Review focused assessment for integumentary system.

General Survey

• Assess physical appearance, including age, sex, and level of consciousness (LOC).
• Evaluate skin color, facial features, expression, mood, affect, speech, dress, and personal hygiene.
• Examine body structure focusing on stature, build, contour, nutrition, symmetry, posture, body position, gait, and range of motion.

Vital Signs

• Vital signs include blood pressure, heart rate, respiration rate, temperature, oxygen saturation, and pain assessment.

Blood Pressure

• Measures the pressure in arteries during heartbeats (systolic) and between beats (diastolic).
• Categories:
  • Normal: Less than 120/80 mm Hg.
  • Elevated: 120–129 systolic and less than 80 diastolic.
  • Stage 1 Hypertension: 130–139 systolic or 80–89 diastolic.
  • Stage 2 Hypertension: 140 or higher systolic or 90 or higher diastolic.
  • Hypertensive Crisis: Higher than 180 systolic and/or higher than 120 diastolic (immediate medical attention needed).

Taking a Blood Pressure

• Patient should be seated comfortably; arm level with the heart.
• Consider patient’s caffeine, nicotine intake, and physical activity in the last 30 minutes.
• Use appropriate cuff and select the correct arm.
• Locate brachial artery, position the cuff, and palpate radial pulse.
• Inflate cuff until pulse is obliterated, then relax and inflate again.
• Listen for Korotkoff sounds to determine systolic (Phase 1) and diastolic (Phase 5) pressures.

Interpreting Blood Pressure

• Normal: < 120/80 mm Hg.
• Hypotension: Low blood pressure.
• Orthostatic hypotension: Drop in SBP (>20 mm Hg) or DBP (10 mm Hg) from supine to standing within 3 minutes.

Heart Rate

• Measured using radial pulse focusing on rate, rhythm, and quality.
• Normal range: 60-100 bpm.
• Irregular rhythms require further investigation.
• Assess if all pulses are consistent in strength (strong, weak, or bounding).

Respiratory Rate

• Measures rate, rhythm, and quality of breathing.
• Normal rate: 12-20 breaths per minute.
• Increased work may manifest as use of accessory muscles or changes in posture.

Temperature Measurement

• Normal body temperature around 37°C.
• Measurement methods:
  • Oral: Avoid hot/cold liquids and smoking prior; place under tongue.
  • Axillary: Lower than oral, takes 5-10 minutes.
  • Tympanic: Use appropriate technique for ear canal.
  • Rectal: Requires lubrication, insert 3-4 cm.
  • Temporal: Sweep across forehead and down to earlobe.

Measuring SpO2

• Indicates hemoglobin saturation with light signals.
• Normal SpO2 above 96%, healthy level above 92%, COPD aim for 88-92%.

Pain Assessment

• Onset, location, duration, characteristics, alleviating/ aggravating factors, radiating nature, timing and treatment, severity/scale, and patient understanding.
• Various descriptors include stinging, cramping, grinding, and more.

Documentation

• Essential for effective communication and safe care.
• Document only care provided, decision-making processes, and use client quotes for clarity.
• Follow professional and legal standards for documentation.

The DAR Note Format

• D - Data:
  • Subjective data from patient.
  • Objective data from observations or tests.
  • Interpretation of current patient status.
• A - Action:
  • Document interventions taken.
• R - Response:
  • Outcomes resulting from actions taken.