WEEK 2- GENERAL SURVEY

Question 1

General survey components

Answer 1

General Survey: study of the whole person, covering the general health state and any obvious physical characteristicsShould give an overall impression, a “gestalt” of the patient Objective parameters are used- applies to whole person not just to one body system 4 areas: physical appearance, body structure, mobility & behaviour

Question 2

physical appearance

Answer 2

Physical Appearance age: appears to be stated agesexlevel of consciousness: alert and oriented skin colorfacial features: symmetrical with movement

Question 3

body structure

Answer 3

Stature: height within normal rangeNutrition: weight within normal range Symmetry: body parts equal proportion PosturePosition
Body build, contour: normal proportions

Question 4

mobility

Answer 4

Gait: accurate foot placement, smooth walk ROM: full mobility of each joint, coordinated movement

Question 5

behaviour

Answer 5

Facial expression: maintaining eye contact, expressions appropriate Mood and affect: comfortable and cooperative
Speech: clear and understandable articulation
oFluent stream of talking, with even pace
oConveying ideas clearly
oWord choice appropriate Dress: clothing appropriate for climate, situation etc. Personal hygiene: appearance clean and groomed appropriately

Question 6

measurement- weight and height

Answer 6

Weight & Height
Remove shoes and outer clothing
Show comparison to recommended weight Feet, shoulder and buttocks should be in contact with the wall (height)

Question 7

measurement- BMI

Answer 7

Marker of optimal weight for height Indicator of obesity or malnutrition BMI = weight (in kilograms) divided by height (in metres) OR weight (in pounds) divided by height (in inches) x 703

Question 8

measurement- waist to hip ratio

Answer 8

Body fat distribution Greater fat proportion in the upper body (especially abdomen) have android obesity
Greater fat proportion in the lower body has gynoid obesity
Waist to hip ratio = waist circumference/hip circumference

Question 9

Vital sign components

Answer 9

temperature
pulse
respirations
blood pressure
oxygen saturation

Question 10

average temperature

Answer 10

37 degree Celsius

Question 11

ways to measure temperature

Answer 11

oral- most common
rectal- most accurate, infants, most invasive
tympanic
axillary

Question 12

temperature is influenced by what?

Answer 12

-diurnal cycle- daytime cycle
-menstural cycle
- exercise
- age- older=less temp

Question 13

how to measure each temp, oral, rectal, axillary, tympanic

Answer 13

Oral temperature procedure:
oMercury free glass thermometer and place on inside of mouth on the sides of the tongue
oLeave in place for 3-4 mins if patient is afebrile and 8 mins if febrile
oWait 20 mins if patient just had hot or cold liquids oWait 2 mins if patient just smoked
oUse an electronic thermometer as well Axillary temperature procedure:
oSafe and accurate for infants and young children- not method of choice for adults due to high insensitivity
Rectal temperature procedure:
oMeasure rectal only when other routes are not practical
oWear gloves and insert a lubricated rectal prove cover on an electric thermometeroInsert only 2-3 cm into the adult rectum directed toward the umbilicus
oFor glass thermometer leave it in place for 2.5 mins
oDisadvantages: patient discomfort, time consuming and disruptive nature of activity Tympanic Membrane Temp procedure:
oTMT senses infrared emissions of the tympanic membrane (eardrum)
oThe eardrum shares the same vascular supply that perfuses the hypothalamus – making it accurate
oCover the probe tip with a tip cover and place probe tip into patient’s ear canal
o2-3 seconds

Question 14

Pulse

Answer 14

stroke volume: with every beat the heart pumps 70 ml of blood into the aorta othis causes the arterial walls to widen and generates a pressure wave, which is felt as the pulsepalpate the radial pulse at the flexor of the wrist laterally along the radius bone – count the # of beats in 30 seconds and multiply by 2 (if beat is regular)count to 60 seconds if beat is irregular (atrial fibrillation) assess the rate, rhythm, force, and equality (when comparing pulses bilaterally)all symmetrical pulses should be assessed simultaneously except for the carotid pulse

Question 15

pulse consists of 3 components

Answer 15

rhythm
force
rate

Question 16

rate- pulse

Answer 16

normal resting heart rate is 50-95 beats/min
rate varies with gender-after puberty, girls have faster rate a resting heart rate <50 beats/min = bradycardiaooccur normally in well-trained athlete
othe stronger heart muscle pushes out a larger stroke volume with each beat, tf fewer beats per min to maintain a stable cardiac output
Cardiac Output = stroke volume x rate
A more rapid resting heartrate over 100 beats/min is tachycardia
oRapid rates occur normally with anxiety or exercise

Question 17

rhythm- pulse

Answer 17

Normally has an even tempo
Sinus arrhythmia: heart varies with the respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration
oInspiration causes a decreased stroke volume from the left side of the heart therefore- heart rate increases

Question 18

force- pulse

Answer 18

Force of the pulse shows the strength of the heart’s stroke volume
Weak thready pulse: decreased stroke volume (occurs with hemorrhagic shock)
Full bounding pulse: increased stroke volume, as occurs with anxiety, exercise etc,
Pulse force is recorded on a 3-point scaleo3+ full bounding o2+ normalo1+ weak, threado0 absent most healthy adults have a force of +2

Question 19

respirations

Answer 19

maintain position of counting radial pulse and count the respirationscount for 30 secs to 1 minute inspiration and expiration = 1 full cycle
respiratory rates are higher in children and infants
pulse rate to respiratory rate is constant at 4:1 normal respiratory rates (breaths/min)
neonate: 30-40
o1 year: 20-40
o2 years: 25-32
o4 years: 23-30
o8-10 years: 20-26
o12-14 years: 18-22
o16 years: 12-20
oadult: 10-20

Question 20

Blood pressure procedure

Answer 20

the force of the blood pushing against the side of the vessel wallsystolic pressure: maximum pressure felt on the artery during left ventricular contraction (systole)
diastolic pressure: elastic recoil, or resting, pressure that the blood exerts constantly between each contraction
pulse pressure: the difference between the systolic and diastolic oreflects stroke volumethe mean arterial pressure (MAP): the pressure forcing blood into the tissues, averaged over the cardiac cycle
average BP is influenced by different factors:
oage: BP rises through childhood and into adult yearsosex: before puberty there is no difference, after puberty girls have a lower BP than males, after menopause BP is higher in women
oethnocultural considerations: African descent usually have higher BP than European oweight: BP is higher in obese patients
oexercise: increasing activity increases BP
oemotions: BP rises with fear, anger and pain as a result of stimulation of the sympathetic nervous system
ostress: BP rises with elevated tensionthe level of BP is determined by 5 factors:
ocardiac output: if the heart pumps more blood into the blood vessels, the pressure on the vessel walls increase
operipheral vascular resistance: opposition to blood flow through the arteries, when blood vessels become smaller (constricted), greater pressure is needed to push the blood through ovolume of circulating blood: refers to how tightly the blood is packed into the arteries. Increasing the volume of blood increases the pressure
oviscosity: the thickness of blood is determined by its formed elements, the blood cells. When blood is thicker, the pressure increases
oelasticity of vessel walls: when walls are stiff and rigid – more pressure is needed to push blood BP is measured with a stethoscope and an aneroid sphygmomanometer oMust be recalibrated once a year and rest at 0 Arm Pressure Procedure: Take 3 measurements separated by 2 minutes – discard the first reading and average the other two Do both arms for the first reading – a 5 to 10 mm Hg difference may occur oIf difference of >20mm Hg continue measuring both arms for duration Feet flat on the floorPalpate the brachial artery, located above the antecubital fossa and centre the deflated cuff about 2.5 cm above the artery and wrap it evenly around arm Auscultatory gap: period when Korotkoff’s sounds disappear during auscultation Inflate the cuff until the artery pulsation is gone and then 20-30mm Hg beyond
Deflate the cuff quickly, then wait 15-30 seconds before reinflating Phase 1  first appearance of soundPhase 4 muffling of soundPhase 5  disappearance of sound oNow used to define diastolic pressure
oWhen variance is greater than 10-12 mm Hg between phases IV and V- record both phases along with the systolic reading Seated BP’s  determine and moniter treatment decisions Standing BP’s diagnose postural hypotension

Question 21

hypotension

Answer 21

In normotensive adults: <95/60In hypertensive adults: >95/60
In children: < expected value for age Occurs with: Acute myocardial infarction
 decreased cardiac output
Shock
 “Hemorrhage  decrease in total blood volume
Vasodilation
 decrease in peripheral vascular resistance

Question 22

hypertension

Answer 22

Essential or primary hypertension – has no cause but is responsible for 95% of hypertension in adults Cardiovascular risk stratification in patients with hypertension
Major risk factors: Smoking
Dyslipidemia
Diabetes mellitus
Age >60 years
Gender (men and postmenopausal women)
Family history of cardiovascular disease

Question 23

somatic pain

Answer 23

superficial (superficial somatic or cutaneous pain)- derived from skin surface and subcutaneous tissues or deep (deep somatic pain) derived from joints, tendons, muscles, or bone

Question 24

visceral pain

Answer 24

originates from the larger interior organs (kidney, intestine, gallbladder and pancreas)
Pain can stem from direct injury to the organ or from stretching of the organ as a result of tumour, ischemia, distension, or severe contraction
Can be constant or intermittent, and may be poorly localized or referred to another area of the body
Ex. Ureteral colic, acute appendicitis, and pancreatitis

Question 25

referred pain

Answer 25

Originates in one location but is felt at another site Both sites are innervated by the same spinal nerve- difficult for the brain to differentiate the point of origin oEx. When the appendix is inflamed, pain may be felt in the periumbilical area

Question 26

2 types of pain

Answer 26

chronic acute

Question 27

chronic pain

Answer 27

Pain that has been present for 6 months or longer than the time of expected tissue healing Malignant (cancer-related pain) or non-malignant oMalignant often parallels the pathological process created by the tumour cellsThe pain is induced by tissue necrosis or stretching of an organ by the growing tumour oNon-malignant pain is often associated with musculo-skeletal conditions (arthritis, low back pain, and fibromyalgia Unrelieved acute pain can lead to chronic pain through 2 processes: oPeripheral sensitization: the reduction of the pain threshold and an increased response of the peripheral end of the nociceptors oCentral sensitization: an increase in excitability of neurons within the CNS

Question 28

acute pain

Answer 28

Short term and self-limiting Follows a predictable trajectory and dissipates after an injury heals Ex. Surgery pain, trauma and kidney stones Serves a self-protective purpose: it warns of actual or potential tissue damage

Question 29

developmental considerations- infants

Answer 29

Infants have the same capacity for pain as do adults 20 weeks’ gestation- ascending fibres, neurotransmitters and cerebral cortex are developed and functioning to the extent that the fetus can feel painoinhibitory neurotransmitters are in insufficient supply until birth at full term- preterm infants are more sensitive to painful stimuli repetitive and poorly controlled pain can result in life-long adverse consequences- neurodevelopmental problems, poor weight gain, learning disabilities, psychiatric disorders, and alcoholism children older than 2 can report pain and point to its location but are unable to rate pain intensity

Question 30

older adults

Answer 30

- pain is not a normal process of aging - pain indicates injury or disease

Question 31

OPQRSTUV

Answer 31

Onset Palliative or provocative quality region/radiation severity timing understanding of pain values

Question 32

O- ONSET

Answer 32

O: onset When did the pain start?To identify onset of pain (when active, or resting) or whether pain is acute/chronic

Question 33

P- PROVACTIVE/PALLAITIVE

Answer 33

Does your pain increase with movement/activity?Are the symptoms relieved with rest? Were any previous treatments effective? To identify quality of pain and differentiate between nociceptive and neuropathic pain mechanisms To identify alleviating and aggravating factors To evaluate effectiveness of current txt

Question 34

Q- QUALITY

Answer 34

Quality of the pain What does your pain feel like? What words describe your pain? To identify mechanism of pain (adjectives

Question 35

R- REGION/RADIATION

Answer 35

R: region of the body/radiation Where is your pain?Does the pain radiate/move to other areas? To identify one or more areas of the body that are affected by pain

Question 36

S- SEVERITY

Answer 36

S: severity of pain How would you rate your pain on an intensity scale?To identify intensity To identify degree of impairment and effect on quality of life or ability to perform ADLs

Question 37

T- TIMING

Answer 37

T: treatment/timing What treatments have worked for you in the past? Is it a constant, dull, or intermittent pain? To identify txt that have been successful in the past To identify the timing of the pain so that the treatment can be focused on spikes in pain

Question 38

U- UNDERSTANDING OF PAIN

Answer 38

U: understanding of pain What do you believe is causing the pain? To understand patient history of pain To be able to set achievable pain and function goals when reviewing the plan of care

Question 39

V- VALUES

Answer 39

V: values What is your acceptable level for this pain? Is there anything else that you would like to say about your pain? Are there any other symptoms related to the pain? To understand and discuss other stressors, spiritual pain

Question 40

face pain scale

Answer 40

The faces pain scale – revised (FPS-R) oGood for children or people who do not speak English o6 faces that show pain intensity from ‘no pain’ to ‘very much pain’