General Survey

Spasticity

Alteration in muscle tone manifested as increased tonicity

Increased resistance when attempting to extend a joint

Rigidity

Alteration in muscle tone manifested as resistance to any movement

Fasciculation

Alteration in muscle movement seen as continuous twitching

Myoclonus

Alteration in muscle movement seen as sudden jerking

Tic

Alteration in muscle movement shown as involuntary, repetitive movement of a muscle group

Tremors

Alteration in muscle movement resulting in rhythmic movement

Stadiometer

Measures Height

Client should remove shoes and stand erect with back toward pole

Measured in feet and inches or centimeters

Underweight

< 18.5 kg/m

or < 12.432 lbs/foot

Healthy weight

18.5 to 24.9 kg/m

Overweight

25 to 29.9 kg/m

Obese

> or equal to 30 kg/m

Kyphosis

excessive, outward curvature of the upper spine (thoracic region) that causes a hunched or slouched posture

“hunchback”

Lordosis

An exaggerated inward curvature of the lower back (lumbar spine) or neck (cervical spine), pulling the abdomen and pelvis forward and creating a "swayback" look

Normal Body Temperature

Between 36 and 38 degrees Celsius

~ 37 degrees Celsius / 98.6 degrees Fahrenheit

Between 96.8 and 100.4 degrees Fahrenheit

Hyperthermia

> 100.4 degrees Fahrenheit

> 38 degrees Celsius

Hypothermia

< 95 degrees Fahrenheit

< 35 degrees Celsiu5

Rectum

The most accurate site for temperature reading

Doppler

A handheld ultrasound instrument that uses the Doppler effect to measure and convert movement (like blood flow or a heartbeat) into audible sound.

Doppler effect = When a source moves toward an observer, its waves are compressed (higher frequency/pitch), and when it moves away, they are stretched (lower frequency/pitch)

The two most common types are fetal Dopplers (for listening to a baby's heart) and vascular Dopplers (for checking blood flow)

Radial pulse

Wrist pulse

Easiest to access, used most frequently

Temporal pulse

Forehead pulse

Carotid pulse

Neck pulse

Measure here if patient pulse is unstable

Brachial Pulse

Elbow bend pulse

Femoral Pulse

the heartbeat felt over the femoral artery, located in the groin area. It is a critical artery for assessing blood flow to the lower extremities, evaluating central circulation, and estimating blood pressure during emergencies

Popliteal pulse

the heartbeat felt in the popliteal artery, located in the soft, diamond-shaped space directly behind the knee (the popliteal fossa). It supplies oxygenated blood to the knee, calf, and foot

Posterior tibial pulse

a crucial indicator of blood flow to the lower extremities. It is located on the inside of the ankle, in the groove between the bony bump (medial malleolus) and the Achilles tendon. It is routinely assessed during physical and vascular exams

Pedal pulse

the arterial pulse felt in the foot. It is primarily assessed at two locations to check blood flow to the lower extremities: the top of the foot and the inner ankle

Apical Pulse

Measured at apex of heart. Provides the most accurate reading of heart rate and rhythm. Measure here if patient pulse is unstable.

How to Take a Regular Pulse

Count the number of pulsations for 30 seconds then multiply by 2

How to take an Irregular Pulse

Count the number for a full 60 seconds

Average adult resting heart rate

60 to 100 BPM

Adolescent heart rate

50 to 90 BPM

Bradycardia

< 60 BPM

Tachycardia

> 100 BPM

Pulse Strength 0

Absent

Pulse Strength +1

Weak, thready, diminished

Pulse Strength +2

Normal and brisk

Pulse Strength +3

Increased, strong

Pulse Strength +4

Bounding, full volume

Apical pulse location

Over 5th intercostal space at midclavicular line

Normal pulse oximetry

95% - 100% Blood O2 Level

Hypoxia

< 90% Blood O2 Level

Normal Adult Respirations

12 to 20 Breaths per minute

Normal Adolescent Respirations

16 to 20 breaths per minute

Bradypnea

< 12 Breaths per minute

Tachypnea

> 20 breaths per minute

Apnea

Absent / No breaths per minute

Systolic Blood Pressure

Normal = < 120 mmHg

Heart Contraction

Maximum Pressure

Diastolic Blood Pressure

Normal = < 80 mmHg

Cardiac Output

Increase in cardiac output leads to increase in blood pressure

Decrease in cardiac output leads to decrease in blood pressure

Vasoconstriction

Increased Vascular Resistance

Leads to increase in Blood pressure

Vasodilation

Decreased Vascular Resistance

Leads to decrease in Blood pressure

Fluid retention

Vol. of circulating blood

Leads to increase in Blood pressure

Hemorrhages

Vol. circulating blood

Leads to decrease in Blood pressure

Viscosity

Increase associated with increase in blood pressure

Rigidity

Elasticity of vessel walls

Increasing rigidity associated with increase in blood pressure

Korotkoff sounds

A clear, rhythmic thumping

Systolic Pressure

Appropriate sized blood pressure cuff

Length = 80% of circumference

Width = 40 % circumference

Hypotension

Systolic < 90 mmHg

Diastolic < 60 mmHg

Elevated Blood Pressure

Systolic from 120 to 129 mmHg

Diastolic < 80 mmHg

Hypertension Stage 1

Systolic 130 - 139 mmHg

Diastolic 80 - 89 mmHg

Hypertension Stage 2

Systolic > 140 mmHg

Diastolic > 90 mmHg

Newborn Heart Rate

120 - 160 Beats Per Minute

140 BPM Average

Toddler Heart Rate

90 - 140 BPM

110 Average

Child Heart Rate

75 - 100 BPM

85 Average

Newborn Respiratory Rate

30 - 60 Breaths per minute

Toddler Respiratory Rate

24 - 40 Breaths per minute

Child respiratory rate

18 - 30 Breaths per minute

Newborn Blood Pressure

Systolic 60-90 mmHg

Diastolic 20-60 mmHg

Usually not taken until 3 years of age

Toddler Blood Pressure

80 - 112 mmHg Systolic

50 - 80 mmHg Diastolic

Child blood pressure

84 - 120 mmHg systolic

54 - 80 mmHg diastolic

Visceral Pain

Occurs in the larger internal organs

Deep, cramping, squeezing, dull

discomfort originating from internal organs (heart, lungs, digestive system, bladder, and reproductive organs) in your chest, abdomen, or pelvis

Somatic Pain

Associated with muscles

Throbbing or deep and achy

pain that originates in your skin, muscles, joints, bones, or ligaments

Provocation/Palliation Quality Region Severity Timing

PQRST

Identify Situation Background Assessment Recommendations Read back Orders

ISBARR

Onset Location Duration Characterization Aggravates/Alleviates Related Symptoms Treatments Severity

OLDCARTS

Past medical history

Last Oral intake

Events leading to Illness

Allergies and reactions

Symptoms or complaints

Each medicine or supplement taken

PLEASE

Gravida Term Preterm Abortions Living children

GTPAL