General survey & Vitals

inspections of patient (6)

1. level of consciousness
2. signs of distress


1. apparent state of health
2. pain or respiratory
3. body habitus


1. obese, cachectic
4. posture/gait/mobility
5. facial expression
6. grooming/dress/hygiene

Where is the radial pulse

radial a is medial to the distal radius

anterior and distal forearm

how to find arterial pulse

palpate radial a and count 30s x 2 → if abnormal count entire minute

normal pulse rate

60-100 bpm

how to document pulse

80 BPM, right radial artery

other options beside radial for pulse

carotid, femoral, apical

normal respiration

14-20 breaths / minute

document for respiration

16 breaths per minute, quiet, regular

where is brachial a

medial to bicep tendon

how to find true systolic?

palpate radial pulse

inflate cuff

note when disappears and add 30 seconds mm Hg to this number

what occurs if BP taken with cuff that is too small

false elevated reading

what occur if BP taken with cuff that is too large

read low on small arm but read high on large arm

tilt test

test orthostatic changes


1. take BP and pulse in supine resting position
2. have patient stand and recheck BP and pulse

positive tilt test values

a drop of >20 mm Hg systolic BP, >10mm Hg diastolic BP, or increase in HR 20 bpm within 3 minutes of standing

normal oral temperature

98\.6 F

37 C

normal temperature range

96\.4-99.1 F

35\.8-37.3 C

T/F rectal temperatures are higher than oral

True

how much higher are rectal temp than oral

average 0.7 -0.9 F or

.4-.5 C

T/F axillary temp are higher than oral

F- lower

how much lower are axillary temp than oral

1 degree F and C

how long rectal temp take to register? Axillary?

3 minutes

5-10 minutes

T/F tympanic temperature is higher than oral

T- because measures core body temp

how much higher is tympanic temp than oral

1\.4 F or .8C

how to document temperature

98\.6 degree F, oral

how to document height

feet’ inches ‘‘

note with or w/o shoes and socks

under 3 y/o given as length in cm

conversion inches to cm

1 in =

2\.54 cm

how to document weight

lbs or kg

note with or w/o clothing inclusive of shoes

infants should be w/o clothing/diapers

conversion kg to lbs

1 kg =

1 lb =

2\.2 lbs

.454 kg

calculate BMI

weight in kg/ (height in meter)^2

LOC

awake, alert, oriented

\
x3

answer ? of self, place, time

\
responsive

Ex: AA&O x 3

what is a general survey

assessment of specific aspects of patient you get from OBSERVING the patient, assessment of patients current state of health, review of constitutional symptoms

key components of general survey, VS and pain assessment

1. perform general survey
2. measure height, weight, BMI
3. BP
4. orthostatic (if needed)
5. pulse, HR, Rhythm
6. breathing (rate, rhythm, depth, effort)
7. temp
8. assess acute vs chronic pain

confused and delirious

• disoriented to surrounding

• may have impaired judgement

• may need cues to respond to commands

• restless, agitates

• notable delusion / hallucination

lethargic

* drowsy
* need verbal and touch stimulation to initiate response
* will respond appropriately

obtunded

* needs repeated stimulation to maintain attention and response
* make eye contact
* speak slowly

stuporous

* respond only minimally to vigorous stimulation
* may only moan as verbal response

comatose

* cant be aroused
* no observable response to any external stimuli
* no purposeful movement

GSE scale

(AVPU) Alert, Voice, Response to Painful stimuli, unresponsive

(EMV) Eye, motor, verbal response

A corresponds with … GSC level

15

V corresponds with … GSC level

13

P corresponds with … GSC level

8

U corresponds with … GSC level

3

GSC scale

3 (unresponsive) - 15 (alert)

what does

coma

reduced consciousness

how would you expect a A&O x 4 patient to act

awake, oriented and talking, capable of higher level thought

(normal)

signs of distress (5)

1. cardiac or resp
2. pain
3. poor eye contact
4. fidgety/anxious
5. depressed

cardiac / resp distress signs

* diaphoresis (excessive sweating)
* labored breathing
* wheezing
* difficultly speaking
* cough / choking

pain distress symptoms

winching or clutching painful area

body habitus / build

muscular, slender, stocky, frail, average

symmetric vs symmetric

survey of skin (7)

1. skin color and lesion
2. pallor
3. cyanosis
4. jaundice
5. rashes
6. bruises
7. wounds

Why is appropriate dressing important to observe

Patient with schizophrenia has problems regulating body temp and may wear inapp clothing for that season

\
shoes indicate homelessness

\
hygiene

\
hair, skin, nails

\
wearing med alert bracelet

facial expression

observe at rest and during conversation and during exam

eye contact, natural, sustained, averted

smiling, flat, crying

immobile facial expression may be sx of …

parkinsons

excessive staring may be sx of …

hyperthyroidism

Nystagmus (uncontrolled eye movement) may be sx of …

tumor

averted eye contact may be sx of …

depression

fruit body odor may be sx of …

diabetes

ammonia body odor may be sx of …

CKD (chronic kidney disease)

body odor may be sx of …

GI bleed, gangrene, abscess

cachectic

weakness and wasting of body due to chronic illness

posture / gait / motor activity

observe when walking to table and/or sitting

fidgety

involuntary motor activity

immobile body parts

limping

note where/how pt is sitting upright/ forward-leaning

sniffing position

tri-podding

ex) sitting upright on the exam table

vitals (6)

1. height and weight
2. temp
3. HR
4. resp rate
5. BP


1. constitutional sx - pain

BMI categories

< 18.5 = underweight

18.5 - 24.9 = normal weight

25 - 29.9 = overweight

30 - 34.5 = obese (class I)

35 - 39.9 = obese (class II)

40+ = morbidly obese / extreme obesity (class III)

waist circumference

measure if BMI > 35

if women = >35 and men = >40 in then increased risk of: DM, HTN, CVD

weight loss recommendations -- risk factors (8):

if BMI > 25 AND pt has 2+ risk factors: high LDL, low HDL, high triglycerides, high blood glucose , HTN , FHx of CVD, physical inactivity, smoking

temperatures methods (5)

1. oral
2. rectal
3. tympanic
4. axillary
5. temporal

bradypnea

slow resp

causes of bradypnea

uremia

durg induced respiratory depression

increased intracranial pressure

tachypnea

rapid and shallow breathing >20 breaths/min

causes of tachypnea

salicylate intox

restrictive lung disease

pleuritic chest pain

hyperpnea, hypervent causes

rapid, deep

exercise, high alt, sepsis, anemia

obstructive breathing

prolonged expiration

narrowed airway -→ increased

resistance to airflow→ longer time expirate

apnea

no breaths

cheyne-stokes breathing

period of deep breathing, alt with apena

causes of cheyne-stokes breathing

HF

uremia

drugs

brain damage

\*may be normal in children / older adult sleeping

turner syndrome causes and characteristic

missing or incomplete sex chromosome

female born w/ only 1 X chromosome

short stature, delayed puberty, infertility, head defect and learning disability

marfan syndrome

affects connective tissue (heart, eyes, blood vessels, bones)

tall and slender, long arms, legs, fingers and toes

biot's breathing (aka "ataxic breathing")

periods of apnea, alternating with regular deep breath

some causes: Meningitis, brain damage, resp distress

Kussmauls respirations (hyperpnea)

deep breathing to compensate for systemic acidosis

cause: DKA

blood pressure -- definition, determinants (3)

tension exerted on arterial walls by blood flow (mmHg) determinants: 1) ventricular contraction 2) arterial and capillary resistance 3) elasticity of arterial walls

BP categories

tension exerted on arterial walls by blood flow (mmHg) determinants:

1) ventricular contraction

2) arterial and capillary resistance

3) elasticity of arterial walls

hypertension

on avg of 2 readings, on 2 sep occasions that is > or equal to 140/90

manual BP pro/con

pro: common, inexpensive

con: subject to white coat syndrome, tech dependent, requires ambulatory or home monitoring to detect HTN

automated BP -- pros/cons

pro: optimal pt positioning

con: requires confirmatory measurement

home BP monitoring -- pros/cons

pros: accurate, automated device, less expensive than ambulatory monitoring

cons: requires pt education, repeated measurements (2x morning, 2x evenings, x 1 week)

ambulatory BP monitoring -- pros/cons

pros: gold standard, records BP every 15-20 mins for 24-48 hrs

cons: more expensive

BP cuff guidelines

bladder length should be ~80% of arm circumference

bladder width should be ~40% arm circumference

standard cuff bladder = 12 x 23 cm

if obese 16 cm or thigh cuff

orthostatic hypotension

a fall in BP after standing due to: intravascular volume depletion autonomic reflex impairment

caused by: medication, blood loss, dehydration, bed rest, ANS disease

diagnose w/ tilt test

adaptive vs maladaptive pain

acute, protect organism from injury, promote healing post injury vs. chronic, pathological functioning of NS

types of pain (4)

1. nociceptive pain

2. neuropathic pain

3. central sensitization pain

4. psychogenic / idiopathic pain

nociceptive pain

somatic pain / damage to tissue

intact sensory - nervous sytem

neuropathic pain

arises from abnormal neural activity secondary to NS disease, injury, or dysfunction

PNS lesion - complex regional pain syndrome, - post-herpetic neuralgia, trigeminal neuralgia, diabetic neuropathy, CNS lesion, phantom limb pain, spinal cord injury, stroke pain

central sensitization pain

alteration of CNS processing sensation

lead to amplification of pain signals

lower pain threshold

psychogenic / idiopathic pain

pain due to other factors:

anxiety

personality

cultural norm

social

constitutional symptoms (6-10)

1. fatigue

2. weakness

3. fever / chills

4. night sweats

5. weight change

6. pain

7. sleep disturbances

8. somnolence (abnormal drowsiness)

9. insomnia

10. irritability

fatigue

sense of weariness or loss of E

nonspecific/many causes

if not sue to normal causes (hard work, stress, grief) -→ further investigation

weakness

evident loss of muscle power on physical exam

associated with neurologic conditions

TIA / CVA, diabetic neuropathy, guillain-barre syndrome (GBS), myasthenia gravis (MG), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS)

fever -- follow up questions (8)

1) how / when did you take you temp? \n 2) what was your highest temp? \n 3) have you used any anti-pyretic? when last? \n 4) any sick contact or exposure? \n 5) any recent travel? \n - infectious exposure \n - clot / DVT \n 6) animal exposure? \n - allergic rx \n 7) new medications? \n - drug fever \n - serotonin syndrome \n - NMS \n 8) recent procedures? \n - wound infection \n - bacteremia \n - atelectasis

night sweat

drenching sweat require change of sheet or pj

weight change -- questions (9)

1) how much weight gained/lost? \n 2) over what time period? \n 3) what was your weight 1 yr ago? \n \n 4) new medications? \n 5) lifestyle (exercise, diet) changes? \n 6) recent disability or injury? \n 7) associated symptoms? \n 8) depression or anxiety? \n 9) change in sleep? daytime drowsiness?