Unit 6 - General Survey, V/S, Pain Assessments

Question 1

During appraisal of the whole person, what are the four areas that you should consider?

Answer 1

Physical appearance
Body structure
Mobility
Behaviour

Question 2

What are you assessing for in Physical appearance?

Answer 2

Age, Sex, Level of Consciousness

Skin Colour, Facial features

Question 3

What are you assess for in Body Structure ?

Answer 3

Statues, Nutrition, Symmetry

Posture, Position, Body Build

Question 4

What are you assessing for Mobility?

Answer 4

Gait, Range of Motion

Question 5

What are you assessing for Behaviour?

Answer 5

Facial expression, Mood and Affect

Speech, dress, personal hygiene

Question 6

Normal limits for Vital Signs

Answer 6

T - 36 to 38 Degrees
P - 60 to 100 bpm
R - 12 to 20 breaths/min
BP - <120-130 / <80-85
130-139 /85-89 = high normal 
SPO2 - 92 to 100%

Question 7

What may affect temperature?

Answer 7

Diurnal/circadian cycle,menstruation/menopause
exercise, age, environment and stress

Note: Newborns CANNOT regulate their body temp

Question 8

What are the considerations for taking temp?

Answer 8

Assess 2 mins if pt smoked
5 mins after chewing gum
20 mins if ingested hot/cold liquids/foods

Question 9

What does Pyrexia mean?

Answer 9

Fever, also known as febrile

Question 10

What is Hyperthermia?

Answer 10

Increased temp

Body cannot regulate our temperature, IE: Heatstroke

Question 11

What is Hypothermia

Answer 11

Decreased temp

Question 12

What is Hypovolumia?

Answer 12

If the volume of our blood is low, heart rate will go up to compensate for the missing volume.

Question 13

What may influence pulse?

Answer 13

Age, exercise, Emotions, Pain, Medications

Body positions, hypovolumia.

Question 14

Considerations for measuring Pulse?

Answer 14

Assess by waiting 5-10 mins after activity

If irregular pulse (A-FIB - extra beat) , count for the full min.

Question 15

What is Tachycardia?

Answer 15

Rapid pulse of beats over 100 per min

Question 16

What is Bradycardia?

Answer 16

Slow pulse of under 60 beats per min

Question 17

How do you assess force/strength of a pulse? (Hint: Numerical)

Answer 17

0- Absent
1+ - weak/thready
2+ - Strong/normal
3+ - Bounding

Question 18

What may influence respirations?

Answer 18

Exercise, Pain, Anxiety, Smoking, Body positions

Medications, Brain injury, sleep

Question 19

What is Systolic Pressure measuring?

Answer 19

Ventricular contractions

AKA how hard your heart has to push to pump to your arteries

Question 20

What is Diastolic pressure measuring?

Answer 20

Resting, filling of the heart

Question 21

What is mean arterial pressure?

Answer 21

Average pressure over cardiac cycle

Question 22

What may influence blood pressure?

Answer 22

Age, Ethnocultural background, wt, emotions, gender

Diurnal rhythm, exercise, stress, medications

Question 23

Considerations when assessing BP

Answer 23

Rest at least 5 mins (wait 60 if pt has ingested coffee or smoked)
Sit supported, feet flat on floor
Arm at level of heart, palm up

Question 24

Common errors when taking BP measurements ?

Answer 24

Inaccurate cuff size
Taking pressure when patient Is anxious, angry or has been active
Faulty technique (Arm position, failure to palpate radial)

Question 25

What is Hypotension?

Answer 25

Low Blood Pressure

Question 26

What is Hypertension?

Answer 26

High Blood Pressure

Question 27

What is Orthostatic (Postural) Hypotension?

Answer 27

Getting up to fast from a sitting to standing position.

Question 28

What are some changes in vital signs when pain is experienced?

Answer 28

Temp - Diaphoresis with acute pain (sweating) Pulse - tachycardia with acute pain, bradycardia with unrelieved or severe pain Resps - Shallow and increase with acute pain, irregular with severe pain BP- Increased with acute pain, may decrease with severe pain Patients may NOT show any changes in vital signs

Question 29

What is the 4 phases of pain (Nocioception) through the nerve pathway?

Answer 29

Transduction Transmission Perception Modulation

Question 30

What is acute pain?

Answer 30

Pain that causes a sympathetic response (fight or flight), Usually lasts under 6 months sudden pain onset, can be relieved

Question 31

what is chronic pain?

Answer 31

Last over 6 months, persistent and unrelieved pain | may case a parasympathetic response

Question 32

What is and example of Nocioceptive pain?

Answer 32

Source of pain that is a normal response | Examples are visceral pain or deep and superficial somatic pain

Question 33

What is an example of Neuropathic pain?

Answer 33

Abnormal response | Phantom Limb pain, or diabetic neuropathy

Question 34

True or False ? Pain is whatever a patient say it is??

Answer 34

TRUE! You can not feel there pain, therefore can not say that it does not exist. No matter what!