General Survey

Approach to General Survey and Assessment A general survey is the initial appraisal of a client’s overall presentation and behaviors. Perform a quick overall assessment and note any body system issues that will need a focused assessment. Verbal Communication ● ● ● ● Active Listening Express Empathy Be Respectful Show Acceptance Nonverbal Communication ● ● ● ● ● ● Calm and relaxed posture Use gestures to encourage conversation Pleasant facial expression, smiling Ensure personal distance Sit at their eye level Make eye contact without staring Miscommunication A client’s verbal and nonverbal responses will indicate how they interpreted what you said. General Survey Checklist General Appearance ● ● ● ● ● Relative to their age and gender identity Identify any unexpected findings and skin tone Note facial movement and symmetry Assess the level of consciousness Note general cardiac or respiratory status ○ Observe for signs of acute distress Behavior ● Does the client articulate clearly and express coherent thoughts? ● ● ● ● Is the flow of speech evenly spaced? Is the client cooperative? Are the facial expressions fitting for the situation? Is the client appropriately dressed/groomed? Indicators of Abuse, Neglect, and Human Trafficking ● ● ● ● ● ● Does the client avoid eye contact or seem withdrawn/anxious? Is the client alongside an overly attentive companion who answers all the questions? Is the client unkempt or wearing inappropriate/dirty clothing? Does the client have physical injuries that do not align with the explained injuries? Is the client having difficulty walking/sitting due to perineal/rectal pain? Does the client appear to be malnourished or dehydrated? Body Structure ● Does the client have observable body alterations? ● Are body parts symmetrical and proportionate? Mobility ● Focus on gait and range of motion ● Note their ability to move each joint ● Identify involuntary movements Measurement ● Obtain height and weight ● Calculate and evaluate BMI Vital Signs 1. Temperature 2. Pulse ○ Rhythm, rate, and strength 3. Pulse oximetry 4. Respirations 5. Blood pressure Pain ● Observe nonverbal cues ○ Grimacing, lying still, or bracing ● Note subjective questions from the client ● Ask about provocation (what makes pain worse) and palliation (what makes pain better) ● Ask about the pattern, quality/intensity, region, severity, radiation, and start time of pain Appearance Facial Features Expected Findings ● Symmetry of facial features and movements Unexpected Findings ● Expressionless ● Asymmetrical facial features ● Involuntary facial movements ○ e.x., twitching, excessive blinking ● Swelling ● Lesions Emotional State Expected Findings Demonstrates that the client is calm. ● Relaxed posture ● Smiling ● Responsiveness Unexpected Findings This can indicate that the client is in pain, anxious, or upset; may also be expressing anger, distrust, depression, and sadness. ● ● ● ● ● ● Restlessness Grimacing Quietness Uncooperativeness Withdrawn behavior Tearful Eye Contact Expected Findings Making eye contact is expected, but culture and shyness can affect this. Unexpected Findings ● Avoidance of eye contact ○ Can indicate confusion, anxiety, or defensiveness ● A penetrating stare ○ Indicative of negative feelings ● Squinting or staring without blinking ○ Possible manifestations of eye dysfunction Level of Consciousness Expected Findings ● Alert and oriented to person, place, time, and situation ● Based on responses when greeted and asked questions ● Awake or easy to arouse Unexpected Findings ● ● ● ● Confusion, lethargy, stupor, obtundation, and coma Delerium: Acute confusion that occurs suddenly and occasionally Dementia: Chronic, progressive confusion Lethargy: Not fully awake, will quickly drift off with a lack of interaction ○ Can easily awaken when their name is called ● Obtundation: Asleep and only aroused with loud auditory/physical stimulation ○ Confused and uses one-word sentences when awake ○ Falls back asleep without constant stimulation ● Stupor: Unconscious but will respond to physical stimuli/pain with movement or incoherent vocalizations ● Coma: Completely unconscious and no response to physical/painful stimuli Skin Expected Findings Skin is intact and warm to the touch with even tones. Unexpected Findings ● Cool, hot, sweaty/diaphoretic, or clammy skin ● Variations in tone ○ Uneven skin color ○ Pallor: Lighter tone than the surrounding skin ○ Cyanosis: Blueish tone ○ Jaundice: Yellowish tone ○ Erythema: Red-purple tone ● Lesions Behavior Speech Expected Findings ● ● ● ● ● Fluency, pace, and articulation Able to speak easily/appropriately in their primary language Does not struggle to find words for expression Clear speech that is evenly paced Exhibits expression Unexpected Findings Speech can be indicative of a disorder. ● Laryngeal disease: Can only whisper or has a hoarse voice ● Dysarthria: Word choice is appropriate, but speech sounds are unclear ● Aphasia: Considered when the client struggles to find words or express an idea ● Echolalia: Word choice is unusual Speech can show how the client is feeling. ● Sarcastic, unbelieving, or hostile tone ● Anxiety: The pace and volume is fast and loud ● Fear/Shyness: Quiet voice ● Pauses before answering a straightforward question ○ Did not hear the question or are confused ○ Might be developing an answer that is not completely truthful ● Depression: Takes a long time to answer; speech may be quiet and monotone Mood ● Observe emotions expressed verbally and nonverbally ● Determine if the stated mood matches their verbal responses and nonverbal behaviors Affect A physical expression of the client’s mood or how it appears to others Expected Findings ● Mostly pleasant and cooperative ● Nervousness and crying might be expected in some situations Unexpected Findings ● Smiling/laughing while talking about a difficult situation ● Expressionless with a flat affect ○ Can indicate depression Personal Hygiene Observe client grooming, noting body and breath odors. Some aspects can vary with culture, socioeconomic class, and occupation. Grooming Expected Findings: ● Clean clothing that fits well ● Hair and facial hair that is well-maintained ● Nails that are trimmed and clean Unexpected Findings: ● The client can be depressed, have a cognitive disorder, or be abused if dependent: ○ Clothing is mismatched or not buttoned correctly ○ Hair is dirty or uncombed ● Recent weight loss/gain: Clothing is too loose or tight ● The client can have a metabolism issue or trying to hide injuries/needle marks: ○ Wearing long sleeves on a hot day Odor Expected Findings: ● Neutral or pleasant odors for both the body and breath Unexpected Findings: ● Poor oral hygiene: Halitosis (bad breath) ● Unexpected breath odors ○ Alcohol ○ Fruity breath (complication of diabetes, malnutrition, or dehydration) ○ Ammonia (related to kidney disease) ● Liver disease: Musty body or breath odor ● Dental/respiratory infection: Fetid (heavily offensive) odor ● Vomiting due to bowel obstruction: Fecal breath odor Dental Hygiene Observe the lips, gums, teeth, and tongue Expected Findings: ● ● ● ● Lips are smooth and moist Lips are pink-brown and darker than the surrounding skin Gums/gingiva are intact, moist, and firmly attached to the teeth Gums are pale/coral pink-brown ○ Darker skin tones can have a dark line along the gum margin ● Teeth are intact, aligned, and smooth ● Teeth are white-pale yellow (can be grey in some) Unexpected Findings: ● ● ● ● ● Dehydration or excessive licking: Lips are dry and cracked Infection/disease process: Lesions, such as a cold sore or scab Gums are bleeding, swollen, overgrown, spongy, retracted, or discolored Teeth are missing, misaligned, or broken Medication side effects, smoking, poor dental hygiene, excessive fluoridation in water, or dental caries: Brown or dark yellow teeth Body Structure and Mobility Posture Expected Findings ● Standing/sitting upright with ease ● Arms relaxed at sides ● A straight, vertical line running through the outer ear, shoulder, hip, patella, and ankle (plumb line) Unexpected Findings ● ● ● ● ● ● Slumped or rigid posture Immobility/pain (ex. arthritis): Stiff spine and neck that move as one unit Emotional distress: Slumped shoulders, erect and rigid position, or bent posture Dyspnea: Tripod position; Leaning forward with arms resting on knees Abdominal pain: Curled up in a fetal position or guarding the abdomen with crossed arms Fidgeting while standing or sitting Overall Build Expected Findings ● Weight is evenly distributed and within the expected reference range ● Height is within the expected reference range for age ● Extremities are bilaterally symmetrical and proportionate to body size Unexpected Findings ● Height above or below the expected range ● Asymmetry of a body part ○ Ex. elongated or shortened limbs in proportion to body ● Endocrine disorder: Uneven distribution of weight in the face, neck, and trunk Mobility Expected Findings ● Smooth, steady movements ● Feet about shoulder width apart ● Arms move freely and evenly ● Ability to rise from and sit into a chair without using arms as assistance ● Some people might use assistive devices to ambulate Unexpected Findings ● Wide stance ● Staggering, stumbling, shuffling, dragging, lumping, immobility of a leg, guarding, or difficulty coming to a stop ● Inability to rise from and sit into a chair without using arms as assistance Range of Motion Expected Findings ● Conscious, smooth, and coordinated movements ● Symmetry between right and left sides Unexpected Findings ● ● ● ● ● ● ● Limited range of motion Pain with movement Immobility due to paralysis or injury Jerky or uncoordinated movements Hesitancy with movement Asymmetry between the left and right joints Crepitus (cracking sound made when bone surfaces rub against one another) Involuntary movements Can be related to alterations in muscle tone or movement ● Spasticity: Increased muscle tone (tonicity) ○ Ex. increased resistance when extending a joint ● Rigidity: Resistance to any manipulation of the joint ● Fasciculation: Continuous, rapid twitching of a muscle at rest ● Myoclonus: Sudden jerking of a muscle ○ Ex. hiccups, seizure activity, single myoclonic jerk of the arm/leg when asleep ● Tic: Involuntary, repetitive movement of a muscle group related to a neurologic/psychogenic cause ○ Ex. grimaces, winks, and shoulder shrugs ● Tremors: Rhythmic movement of one or more joints; can occur at rest or when attempting voluntary movement Measurements Height 1. Pull up the measuring pole and extend the headpiece 2. Instruct the client to remove their shoes and stand straight with their back to the pole 3. Have the client hold their head up and look straight ahead If the client is unable to stand: 1. Place the client in a supine position on a firm surface 2. Remove their shoes and use a tape measure to determine height from the top of their head to the bottom of their heel Weight 1. Have the client remove shoes and outerwear before standing on the scale 2. If using a balance scale, calibrate it to zero before weighing 3. Have the client stand in the center and adjust the large (50 lb increments) and small (0.25 lb increments) weights to balance If the weight is to be monitored closely in series: ● Weight the client at the same time each day ● Use the same scale and have the client wear the same type of clothing Determine if the client is within the expected reference weight range, underweight, overweight, or obese based on their age and sex. Expected Variations ● Influence by genetics, exercise, diet, and fluid volume ● Genetics determine bone structure and muscle mass Unexpected Findings ● Fluid retention (ex. heart failure): Unintentional weight gain (5 lbs in a day) ● Disease process (ex. fever, infection, malignancy, or endocrine disease: Unintentional weight loss (5% of body weight in a month or 10% in 6 months) BMI Formula(s): ● Weight (lb) / height (in)2 x 703 ● Weight (kg) / height (m)2 BMI classification for adults: ● Underweight: < 18.5 kg/m ● Healthy weight: 18.5-24.9 kg/m ● Overweight: 25-29.9 kg/m ● Obese: > 30 kg/m ○ Increased risk for hypertension, diabetes mellitus, cardiovascular disease, and some cancers Vital Signs Temperature Physiology Thermoregulation is the process the body uses to maintain the core temperature within the optimal range and involves both physiological and behavioral mechanisms. ● Controlled by the hypothalamus, which regulates heat production and loss ○ Uses a negative feedback system ○ Anterior Hypothalamus: Responsible for heat loss ○ Posterior Hypothalamus: Responsible for heat production and conservation ● Thermoregulation may malfunction if the client is ill or has a CNS disorder, impeding nerve communication ● Mechanisms of heat production: ○ Metabolism: Chemical reactions that occur within a cell and produce heat ○ Physical activity and shivering ● Mechanisms of heat conservation: ○ Vasoconstriction, which occurs when the core temperature decreases ○ Decreases blood flow to the extremities and skin ○ Conserves temperature and prevents heat loss through the skin ● Mechanisms of heat loss: ○ Vasodilation, which occurs when the core temperature increases ○ Increases blood flow to the extremities and skin ○ Allows for loss of heat via evaporation, radiation, conduction, and convection Factors Affecting Temperature ● ● ● ● Client’s age Hormonal changes Stress level Diurnal rhythms (highs and lows based on the time of day) ○ Temperature is at its lowest in the early morning (1-4 am) ○ It then rises steadily until peaking in the late afternoon (4 pm) Tools ● Thermometers obtain and measure ● Use a protective probe and clean in between uses ● Electronic options: ○ Thermometer with two probes ■ Blue for oral ■ Red for rectal ○ Tympanic thermometer ○ Temporal artery thermometer ● Disposable thermometers are less accurate but useful for a client in isolation ● Conversion formulas: ○ Fahrenheit to Celsius: C = (F - 32) x 5/9 ○ Celsius to Fahrenheit: F = (9/5 x C) + 32 Ranges ● Oral/tympanic ranges: ○ Expected: 36° to 38° C (96.8° to 100.4° F) ○ Average: 37° C (98.6° F) ○ Older adult: 35° to 36.1° C (95° to 97° F) due to less body fat ● Rectal ranges: Usually 0.5° C and 0.9° F higher than oral ● Temporal/infrared ranges: Nearly 0.5° C and 1° F higher than oral ● Axillary ranges: Usually 0.5° C and 0.9° F lower than oral Oral ● Ensure the client has not smoked or consumed anything recently ○ Must wait at least ten minutes to take their temperature Rectal ● ● ● ● Most accurate but infrequently used Invasive, time-consuming, increases the risk of infection transmission, and uncomfortable Used when a client cannot open their mouth or is comatose Contraindicated if a client has rectal bleeding, diarrhea, rectal disorders, or rectal surgery Temporal ● Accurate when combined forehead and behind-the-ear readings are obtained ● Hold the probe against the center of the forehead and move it across, then behind the ear Axillary ● Longer measurement time and less accurate ● Used infrequently in adults Tympanic ● Quickly and easily accessed; reflects core temperature ● Accuracy can be impacted if the client has been lying on their side, cerumen is present in the ear canal, pathologic variances exist, or infection in the ear is present Infrared ● Quick, easy to use, and reduces the spread of cross-contamination/disease spread ● Thermal radiation is emitted from the frontal bone (forehead) or temporal artery Unexpected Findings Hyperthermia ● Elevated body temperature ● Caused by infection, tissue breakdown, or neurological condition ● Manifestations: ○ ○ ○ ○ ○ Skin can be erythematous, warm, or dry Diaphoresis Dry mucous membranes Change in mental status Seizures Hypothermia ● Low body temperature ● Caused by prolonged exposure to a cold environment or a disease process (ex. shock or cardiac arrest) ● Manifestations: ○ Cool skin that is pale or cyanotic ○ Sluggish capillary refill ○ Shivering ○ Change in mental status Pulse ● A palpable pulsation resulting from the contraction of the heart and resultant blood flow through the peripheral arterial system ● Can determine heart rate, rhythm, and contraction strength ● Pulse points: ○ Radial, which is on the thumb side of the client’s inner wrist ○ Apical and carotid; preferred if the client is unstable or has a poor cardiac output Tools ● Watch or clock with a second hand ● Stethoscope: In case auscultation of the apical pulse is necessary ● Doppler ultrasound: ○ For pulses that are difficult to locate or palpate ■ Clients who are obese, have diminished blood flow, or weak heart contractions 1. Apply a thin layer of transmission gel to the tip of the Doppler transducer or directly onto the client’s skin 2. Using a light touch, so as not to obstruct blood flow, place the tip of the transducer at a 90-degree angle on the client’s skin 3. Adjust the volume control as needed, and reposition the tip on the skin until locating the pulse (note an audible “whooshing” sound) 4. Repeat the procedure as necessary to locate additional pulses 5. Use a water-based solution to clean the gel off the transducer and the client Palpation 1. 2. 3. 4. Apply pressure over the artery with the finger pads of your index and middle fingers Press firmly enough to feel the pulsation but not impede blood flow Identify the rhythm of the pulse to determine regularity If the pulse is regular, count the number of pulsations for 30 seconds and multiply by 2 to measure the pulse rate 5. If irregular, count the number of pulsations for 60 seconds to measure the pulse rate 6. Note the rate, rhythm, strength, and equality of the pulse during palpation Pulse Qualities: Rate and Rhythm ● Determine the pulse rate, the number of pulsations in one minute ● Determine the rhythm, or regularity of the pulsations ● Note if the measured rate is within the expected reference range based on age Expected Findings ● The average/older adult should have a resting heart rate of 60-100 bpm ● The rhythm should be regular, with consistent intervals between each pulsation Expected Variations ● Bradycardia in adults who are physically active ● Hearts that work efficiently allow for a lower heart rate than expected Unexpected Findings: ● Bradycardia, or a pulse rate less than 60 bpm ○ Can occur in conditions like hypothyroidism or hypothermia ○ Can be a side effect of some medications ○ Assess the apical pulse rate and check their current medication ● Tachycardia, or a pulse rate greater than 100 bpm ○ Can be a temporary condition related to pain, effects from medication, anxiety, exercise, or infection with fever ● Arrhythmia/dysrhythmia, or an irregular pulse rate ○ Determine if the irregularity is consistent or inconsistent ■ Regularly irregular (ex. pulse skips every fourth beat) ■ Irregularly irregular, or no consistency in the rhythm ○ Auscultate the client’s heart for a more comprehensive assessment Pulse Qualities: Strength ● Reflects the force of heart contractions, blood volume, and flow of blood to the pulse site ● Measured on a scale of 0 to +4: ○ 0: Absent, impalpable pulse ○ +1: Weak, thready, diminished pulse ○ +2: Normal, brisk pulse (expected) ○ +3: Increased, strong pulse ○ +4: Bounding, full-volume pulse Expected Findings ● Easily palpable, yet neither forceful nor weak Unexpected Findings ● Diminished pulse ○ Weakened heart muscle, hemorrhaging, or poor flow to the pulse site ● Strong, bounding pulse ○ Anxiety, increased activity, or condition causing increased heart contractility and/or blood pressure Pulse Qualities: Equality ● ● ● ● Bilateral symmetry of the pulses Palpate the same location of the pulse on both the right and left sides at the same time Compare the rate, rhythm, and strength of the two pulses Never palpate both sides at the same time on a carotid pulse, which could compromise blood flow to the brain Expected FIndings ● Equality of pulse characteristics bilaterally Unexpected Findings ● A diminished or impalpable pulse on one side ○ Indicative of locally impaired blood flow due to a blood clot or artery malposition Pulse Oximetry ● Readings are percentages of saturation and estimate the arterial oxygen status (SaO2) ● Pulse oxygen saturation (SpO2) provides information about respiratory status Tools ● Pulse oximeter, which detects the amount of oxygen bound to hemoglobin ● Attaches to the client, usually on the finger, nose, forehead, earlobe, or foot ○ Earlobe probes are more reliable if the client has poor peripheral blood flow ● If the SpO2 is less than 70%, the oximeter is not considered reliable Factors Affecting Readings ● Carbon monoxide poisoning, jaundice, painted or thickened nails, recent injection of dyes in the circulatory system, and dark skin tone ● Client movements during testing or interference from external light sources ● Difficulty can be encountered with patients who have impaired circulation ○ Ex. peripheral vascular disease, hypothermia, vasoconstriction, hypotension, and peripheral edema ● Use of oxygen therapy or bronchodilators ● Low hemoglobin levels Assessment ● ● ● ● Assess for changes in oxygen saturation Inspect the skin, nail beds, and lips for cyanosis Observe breathing for an unexpected rate, rhythm, depth, or sounds Assess behavior for irritability, restlessness, or confusion ○ Potential signs of hypoxia Expected Findings ● 95% to 100% Unexpected Findings ● Hypoxia, or an oxygen saturation level below 90% ○ Considered an emergency Respirations ● The exchange of oxygen and carbon dioxide ● Processes of respiration: ○ Ventilation: Total volume of gas inspired or expired per unit of time, usually liters/minute ○ Diffusion: Movement of gases/solutes from an area of greater pressure/concentration to an area of lower pressure/concentration ■ Toward a uniform distribution ○ Perfusion: Movement of blood or other fluid through the blood vessels or other natural channels, organs, or tissues ● Involuntarily regulated by the brainstem Tools ● A watch or clock with a second hand ● The ability to count someone’s breaths without them knowing Assessment ● Assessed by the rate, depth, and rhythm Rate Expected Findings ● 12-20 breaths per minute Unexpected Findings ● Bradypnea: Rate less than 12 ● Tachypnea: Rate greater than 20 ● Apnea: Absence of breaths Depth Expected Findings ● Even, quiet, and regular breathing pattern ● Chest moves observably ● Occasional deep breaths, such as a sigh, are expected Unexpected Findings ● Shallow and deep respirations at altered rates ● Shallow depth is present with minimal chest expansion ● Deep respiration is present with full chest expansion ○ Usually termed as labored Rhythm ● Observe the rate, or number of ventilatory cycles (inspiration and expiration) completed in a minute ● Observe the depth of movement of the chest ○ Shallow, expected, or deep ● Observe the client’s respiratory rhythm ○ Regular or irregular Expected Findings ● Steady, even rate ● Depth that is neither deep nor shallow Unexpected Findings ● Fluctuations in depth and rate ● Must be counted for a full minute for accuracy Factors that Affect Respirations Exercise ● Faster and deeper breathing than expected ● Meets the need for more oxygen and gets rid of carbon dioxide Pain ● Pain in the chest or abdomen area may cause shallow breaths to minimize movement ● Medication used to treat pain can decrease the rate and depth of breathing Anxiety ● Increased rate due to stimulation of the sympathetic nervous system Smoking ● Changes the lining of the airways in the lungs ● Inhibits airflow and makes breathing faster Body Position ● Sitting or standing upright allows for fuller chest expansion ● Being slumped over inhibits full expansion ● Lying down prevents full chest rise Medications ● Those for relieving pain (ex. narcotics) slow the respiratory rate by depressing the CNS ● Stimulants (ex. amphetamines) make breathing faster and deeper Neurological Injury and Hemoglobin Alterations ● A brain injury inhibits the rate and rhythm of breathing ● Less hemoglobin results in less oxygen and, thus, faster breathing ● Sickled blood cells reduce the oxygen-carrying ability of hemoglobin, causing an increase in respiratory rate and depth Blood Pressure ● The force of pulsing blood on the walls of an artery; an indicator of cardiovascular health ● The peak of the maximum pressure in the arteries occurs in systolic pressure ○ The heart contracts and pushes blood into the vascular system ● The minimum pressure in the arteries occurs in diastolic pressure ○ The ventricles of the heart relax, and blood enters the ventricles ● Measured in millimeters of mercury (mmHg) Tools ● ● ● ● Sphygmomanometer to measure arterial blood pressure Stethoscope Alcohol wipe/swam to clean the diaphragm/bell of the stethoscope An electronic blood pressure device can be used ○ Useful when frequent assessments are required, such as during an invasive procedure, during the administration of cardiac medications, or when critically ill ○ Requires the appropriate cuff ■ The length of the bladder within the cuff should cover at least 80% of the limb circumference ■ The width should be about 40% of the circumference of the limb ○ Should not be used due to inaccuracies if the client has hypertension, hypotension with a systolic pressure below 90 mmHg, dysrhythmias, seizures, or experienced traumas Expected Findings ● Below 120/80 mmHg Unexpected Findings ● Hypotension: Below 90/60 mmHg ● Hypertension: 120/80 mmHg to 129/80 mmHg ● Two stages of hypertension: ○ Stage 1: 130-139/80-89 mmHg ○ Stage 2: Greater than or equal to 140/90 mmHg Alternative Cuff Placement ● An injury, cast, IV, or dressing can require the blood pressure cuff to be used on the forearm (radial artery) or thigh (popliteal artery) instead ● When obtaining a lower-extremity blood pressure: ○ Position the client in a prone position or have them flex their knee ○ Place the cuff an inch above the location where the popliteal artery is palpated ○ Expected to be 10-40 mmHg higher than the measurement of the brachial artery Factors Affecting Blood Pressure Smoking ● Causes vasoconstriction ● Results in higher blood pressures Gender ● Males tend to have a higher blood pressure after puberty than females ● Postmenopausal females may have a higher blood pressure than others the same age Ethnicity ● White American clients are less likely to be hypertensive than African American ones ● The African American population has among the highest incidence of hypertension ○ This leads to an increased risk of stroke, heart attacks, and death Diurnal Variations ● Blood pressure increases steadily during the day ● In the late afternoon, it begins to decrease Medications ● Cardiac and antihypertensive medications lower blood pressure ● Opioid analgesics can reslt in hypotension ● Vasoconstrictors and amphetamines can increase blood pressure Obesity ● Tend to have higher pressures compared to others the same age History of Hypertension or Hypotension ● Knowing history helps to determine if the high/low reading is the baseline Variations in Data Collection Procedures Orthostatic Blood Pressure ● 1. 2. 3. ● Involves taking multiple readings in supine, standing, and sitting positions Place the client in a supine position, and wait 3 minutes before taking a reading Keep the cuff in place and sit the client up; wait 1-3 minutes before taking a reading Stand the client up, and wait 1-3 minutes before taking the last reading A drop of 20 mmHg in systolic pressure or 10 mmHg in diastolic pressure between positions indicates orthostatic hypotension ○ A decrease in blood pressure that occurs upon standing Pain Assessment Sources of Pain Visceral ● Begins in the larger internal organs ● Described as a deep cramping, squeezing, or dull pain ● Ex. appendicitis, cholecystitis, and colitis ● Travels along the ANS ● Can include sweating, nausea, and vomiting Somatic ● Associated with the musculoskeletal system ● ● ● ● Originates in the muscles, bones, tendons, ligaments, and blood vessels Described as a throbbing pain or deep achy feeling Ex. broken bones and trauma injuries to the muscles or blood vessels Can include sweating, nausea, and tachycardia Referred ● Pain felt in one area but originates elsewhere ● Ex. cardiac pain that is felt in the left arm or neck Types of Pain Acute/Transient Pain ● Short duration; related to an injury or illness ● Does not last more than 6 months ● Mostly follows a pattern of healing and will resolve once the cause has been addressed Chronic/Persistent Pain ● ● ● ● Lasts longer than 6 months; can last 20 years or more Recurring pain that can be severe May originate in an unidentifiable area Malignant chronic pain: related to cancer ○ Can be caused by necrosis (tissue death) or organ distention ● Nonmalignant chronic pain: unrelated to cancer ○ Can be caused by musculoskeletal conditions (arthritis, low-back pain) and nerve disorders (fibromyalgia, peripheral neuropathy) Collecting Subjective Data Questions to Ask ● ● ● ● ● Do you have pain? Where is your pain? When did it start? Describe the quality. How much pain are you in now? PQRST Method ● Provocation/Palliation: ● ● ● ● ○ What were you doing when the pain started? ○ What makes it better? ○ What makes it worse? ○ What triggers the pain? ○ What relieves the pain? Quality: ○ Describe the pain. ○ Is it dull or sharp? ○ Is it stabbing, throbbing, or cramping? Region: ○ Where is the pain? ○ Does it radiate? ○ Is it localized? Severity: ○ How severe is it? ○ Does it interfere with activities? ○ How long does it last? Timing: ○ What time did it start? ○ How long does an episode last? ○ Is the onset sudden or gradual? ○ Does it occur during the day or night? Numeric Scale ● To make it quantifiable, use a scale from 0-10 ● 0 is no pain, and 10 is the worst pain they can ever imagine ● Ask the client: ○ Where are you on that scale? ○ Where is your pain when you treat it at home? ○ At what level of pain can you remain functional? Collecting Objective Data Objective indicators of pain: ● Swelling, bruising, or inflammation ● Increased heart rate and blood pressure ● Facial grimaces, guarding with movement, clenching teeth, or frowning ● Restlessness; inability to pay attention or stay still When clients have adapted to continuous pain, they might have subtler cues, like massaging, sighing, and decreasing activity. Documentation General Assessment ● ● ● ● ● ● Begin with the results during the initial scan of the client Note the speech rate, rhythm, and pronunciation Include the overall appearance of the clothing, skin, and dentition Document the behavior, mood, and responses to questions Note the mobility, gait, and use of assistive devices, like canes, walkers, and wheelchairs Document measurements, including height, weight, and BMI Vital Signs ● Include the temperature and location taken ● Document pulse findings, such as rate, strength, and location (radial, brachial, or apical) ● Document the pulse oximetry percentage and specify if supplemental oxygen is used, including type and liters/min ● Include rate, rhythm, depth, and effort of breathing for respiration ● Blood pressure notations should include the systolic/diastolic measurement and location of cuff placement ● Note the presence of pain, rating, location, duration, aggravating factors, and treatment ○ Also note the denial of pain