General Survey, Measurement, Vital Signs & Pain Assessment PDF

2/4/24, 9:01 PM OneNote General Survey, Measurement, Vital signs and Pain assessment. Tuesday, January 16, 2024 8:36 AM Key Terms Homeostasis : internal equilibrium of the body state Body Mass Index: correlation between height and weight. Whether client is underweight, overweight or just right. Hype...

2/4/24, 9:01 PM OneNote General Survey, Measurement, Vital signs and Pain assessment. Tuesday, January 16, 2024 8:36 AM Key Terms Homeostasis : internal equilibrium of the body state Body Mass Index: correlation between height and weight. Whether client is underweight, overweight or just right. Hypertension : high blood pressure Hypotension : low Orthostatic hypotension: relates to gravity. When they stand they will get dizzy or lose consciousness. If there is a drop in blood pressure of 20mmHg or more, that's it. If the it. There is always an increase in heart rate, happens when blood pressure drop Tachycardia : high heart rate. Bradycardia: slow heart rate Tachypnea: elevated respiratory rate Bradypnea: low respiratory rate Hyperthermia: elevated temp Hypothermia: low temp Oxygen Saturation: SpO2 Components included in General survey The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. It is an introduction for the physical examinatio give an overall impression, a “gestalt,” of the patient. Physical Appearance : do they look their age, their grooming/hygiene, their body language Body Structure : posture, stature, etc. Objective assessment : ask using facial expression, describe what you see facially, hear and smell. Mobility : Gait, range of motion, etc. Behavior: facial expression, mood, etc. Measurement: Height, Weight/BMI, Waist-Hip Ratio Instruments used in assessment and general survey Otoscope(ears), stethoscope, ophthalmoscope(light), tongue depressors, barcode for identification, pen light for pupil size, hand sanitizer, gloves, tape rule. measurement components related to height, weight, Body Mass Index (BMI), & waist-to-hip ratio: Scale for baby and adult, height chart, tape measure( for babies, it is used when they can stand). BMI calculation A practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition. Nomogram is used to calculate BMI Formula: Weight (in kilograms) Height (in meters)2 BMI Calculations < 18.5 underweight 18.5-24.9 Expected ‘normal’ weight 25.0-29.9 Overweight 30.0-34.9 Obesity, Class 1 35-39.9 Obesity, Class 2 40 Extreme Obesity, Class 3 Children aged 2-19 : BMI is measured against weight percentiles 6 Vital Signs & The Tools used to Measure Vital signs: Crucial element to tell if patient are in homeostatic state or at risk. The 6 vital signs: Blood Pressure, Pulse, Respirations, Temperature, Oxygen Saturation, Pain. Essential tools : stethoscope, Sphygmomanometer, use of eyes and ears, handwashing, hand sanitizing, ppe, cleaning the work station and equipment, Pain reading scale, ox thermometer. Blood pressure Blood pressure: Measurement of Force of blood against blood vessels. Systole: contraction of the ventricles blood ejected and travels through arterial system Diastole: relaxation of the ventricles to allow for blood collection https://yuoffice-my.sharepoint.com/personal/ife20_yorku_ca/_layouts/15/Doc.aspx?sourcedoc={bf93dbc4-cdec-494f-8064-58e33247d86a}&action=edi… 1/4 2/4/24, 9:01 PM OneNote Hypertension and hypotension : when systole is too high or too low Expected blood pressure in an adult is Systolic : 120mmHg+/- 20, Diastolic 80mmHg +/- 10 Numerator – systole and Denominator – diastole. Numerator is always higher than denominator. Two step method is utilized when 1. patient new to service (obtain a baseline) 2. Admission to hospital (obtain baseline) 3. When status changes Once the baseline is established, one step. Korotkoff sounds : Physiologic arterial process that translates to sounds. Sphygmomanometer, when inflated correctly, obliterates blood flow through brachial artery. Inflating the cuff above the systolic pressure of the artery Obliterates blood flow. SLOWLY lowering cuff pressure, releases pressure on the artery, allowing for some blood fl pressure and as pressure valve continues to open, pressure on vessel lessens. Phase 1-vessel pressure lowers to reach intraluminal systolic pressure. Pressure at which artery opens. A sharp thud. Phase 2-turbulent flow artery still opening. A blowing or swishing sound. Phase 3-blood flow through artery heard, stoppage between ‘beats’ is late diastole. A softer thud than phase 1. Phase 4-artery does not close. A softer blowing sound that disappears. Phase 5-velocity of blood flow decreases. Vessel returns to usual state. Silence. Korotkoff sounds Systolic, 3 phases, 1st diastolic, 4th phase, 2nd diastolic, silence. Auscultatory gap : we do 2 step blood pressure because there could be no sound(auscultatory gap) of the Korotkoff. So sound, no sound and then sound. If it is not a 2 step, reading. Mostly happens with people with hypertension. 2-step : Palpate, inflate cuff, determine number, deflate quickly, wait a min, add 20mmHg to what is read, inflate to that number, and deflate. Blood pressure unexpected findings Hypertension: Reading Above 140 systolic or 90 diastolic. Causes: Error in measurement, Unknown but risk factors include: Smoking, Dyslipidemia(high cholesterol), Diabete & post menopausal women, Family history. Hypotension: In normotensive adults 20mmHg or P > 20 bpm Blood pressure unexpected findings due to technique errors. Above level of heart: falsely low Below level of heart: Falsely high Feet not flat on the floor or dangling: Falsely high Cuff size too small: Falsely high Cuff size too loose: Falsely low Overinflation: Pain, hence the 2-step method. Halting deflation and reinflating :Falsely high diastolic Developmental differences related to technique & findings. All patients: Ensure cuff size is accurate. Covers 2/3 of upper arm. Use of language for children, allow them to handle the equipment before applying. Use terms, such as this will ‘hug’ your arm. If there is a ‘doll’ or mannequin in room, put on the mannequin and allow child to inflate bulb. Sit on caregiver lap for assessment. Care giver may help to position arm. Older adults may have slightly higher systolic and diastolic measurements due to changes in blood vessels with aging, less pliant Pulse Rate (beats per minute-bpm), Rhythm (regular or irregular), Force (0-3+). Expected Adult 60-100 bpm/50-95bpm, Regular, Force 2+ How to obtain pulse : palpate radial artery, 30 seconds multiplied by 2 for adults, 1 full minute for kids to check rate in BPM, the rhythm and force. Not to do a pulse : nurse the patient not the equipment. Actually doing it and document, not assuming. Pulse unexpected findings. Tachycardia: >100 bpm/minute Potential Causes (increased metabolism): Anxiety, Fever, Cardiac Causes, Medications, Substance use Bradycardia: < 60 bpm/minute Potential Causes (decreased metabolism): Medications, Substance use, Hypothermia Irregular rate/force : Pulsations irregular tempo Potential Causes: Cardiac Causes, Substance use https://yuoffice-my.sharepoint.com/personal/ife20_yorku_ca/_layouts/15/Doc.aspx?sourcedoc={bf93dbc4-cdec-494f-8064-58e33247d86a}&action=edi… 2/4 2/4/24, 9:01 PM OneNote Force 0-1+: Decreased circulatory volume (stroke volume) Force 3+: Hyperkinetic state, exercise, anxiety, fever, anemia Developmental differences related to pulse technique & findings. Infants/Children under 2 years-obtain pulse rate using apical method. Exception to irregular rhythm: May have irregular rhythm, this is called sinus arrythmia (rate increases on inspiration and slows on exhalation). This is an expected finding in Older adults, if unable to palpate radial, obtain by apical, also check flow with doppler Respirations Part of pulse taken Rate, Rhythm, Effort. Expected: Adult 10-20 bpm (breaths per minute) Rhythm : rise and fall of breathing Effort : are they sitting right etc. Tachypnea: elevated respiratory rate. Bradypnea: low respiratory rate Developmental differences related to RR technique & findings Infants: Count RR by observing the abdominal rise and fall(also in men), not chest(in women). Observe and count for 1 full minute. Tachypnea newborn to 2 months > 60 bpm & 2-12 months is > 50bpm Older Adults: With age comes decrease in vital capacity and a decrease in inspiratory reserve volume. May have shallower respirations and increase in rate. Safety check The ratio of pulse to respirations is 4:1. The correlation may be used to assess accuracy If a pulse was 120 bpm, what would you expect the RR to be? 30 If a pulse was 80 bpm, what would you expect the RR to be? 20 Temperature Expected : Diurnal cycle throughout day may might vary 1C-1.5C, Increases with exercise, Increases with progesterone secretion, Decreases in older adults, Infants may not b fluctuates. Could be checked orally, rectal, the ear(tympanic), over the forehead, armpit(axillary) etc: for ear : Pull up for adult, Pull down for kids Hyperthermia: >37.3 Causes: Metabolic: fever, tissue destruction (injury). Neurologic disorders, loss of temperature regulator. Hypothermia :