216 General Survey, Vital Signs, Pain and Inclusivity terms

General Survey

study of the whole person, covering the general health state and any obvious physical characteristics such as posture dress, behavior, level of consciousness, mobility, distress

Temperature normal range

97.5-99.5 F or 36-37 C

hypothermia

body temperature below 95 F 35 C

fever, pyrexia, hyperthermia

temperature greater than 100 F 37.8 C

oral temperature

should not be used on a patient who cannot follow directions, has decreased mentation, is unable to keep mouth closed or breathes through mouth; standard for adult measurement of temperature

tympanic temperature

taken in the ear; should not be used on patient who is experiencing ear pain, ear drainage or has a large amount of wax

temporal temperature

Measurement of body temperature at the temporal artery on the forehead; usually 0.5 F (0.3 C) lower than oral temp

rectal temperature

temperature taken in the rectum; can stimulate the vagus nerve; contraindicated in rectal surgery, rectal disease, low WBC, blood clotting disorder, neurologic disorders, cardiac disease, diarrhea and hemorrhoids; 0.5 F (0.3 C) higher than oral temp

radial pulse

the pulse felt at the wrist; 60-100bpm expected

apical pulse

pulse taken with a stethoscope and near the apex of the heart

pulse deficit

the apical and the radial pulse rates.

bradycardia

slow heart rate (less than 60 bpm)

Tachycardia

rapid heart rate greater than 100 bpm

pulse volume scale

0 Absent pulse

1+ Weak and thready pulse, difficult to palpate

2+ Normal pulse, able to palpate with normal pressure

3+ Bounding pulse, may be able to see pulsation

Respiratory Rate (RR)

Number of breaths per minute; Adults = 12-20

Tachypnea

Increased breathing rate above 20 bpm

bradypnea

abnormally slow breathing (less than 12 breaths per minute)

depth of respiratory rate

shallow vs deep

rhythm of respiratory rate

regularly spaced or irregularly spaced

respiratory effort

Work of breathing-relaxed easy breaths expected

Dyspnea: labored breathing

Orthopnea: inability to breathe when horizontal

Systolic Blood Pressure (SBP)

The pressure in arteries and other blood vessels when the heart is contracting; the first (top) number recorded.

Diastolic Blood Pressure (DBP)

The pressure in arteries and other blood vessels when heart is at rest or between beats; the second (bottom) number recorded.

blood pressure levels in adults

normal: systolic <120, diastolic <80

elevated: systolic 120-129, diastolic <80

hypertension stage 1: systolic 130-139, diastolic 80-89

hypertension stage 2: systolic >140, diastolic >90

hypertensive crisis: systolic >180, diastolic >120

orthostatic vital signs

blood pressure & pulse taken lying, sitting, & standing and documented indicating the corresponding position

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

objective data

information that is seen, heard, felt, or smelled by an observer; signs

Four key principles to inclusive assessment

1. treat every health assessment as an act of humanity

2. health assessments are not about "sameness"

3. examine your own personal biases

4. cultivate a safe environment of care

Cultural Sensitivity

recognizing and respecting the differences between cultures

cultural competency

the enabling of health care providers to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients

cultural humility

process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners

Cultural safety

Culturally appropriate health services to disadvantaged groups while stressing dignity and avoiding institutional racism, assimilation (forcing people to adopt a dominant culture), and repressive practices.

Pain

is whatever the experiencing person says it is, existing whenever he/she says it does; should be accepted as such and respected

acute pain

short-term, self-limiting, often predictable trajectory; stops after injury heals

chronic pain

Enduring pain that does not decrease over time; may occur in muscles, joints, and the lower back, and may be caused by enlarged blood vessels or degenerating or cancerous tissue. Other significant factors are social and psychological.

intractable pain

severe pain that is extremely resistant to relief measures

intermittent pain

Pain that comes and goes at intervals

phantom limb pain

pain in a limb (or extremity) that has been amputated

radiating pain

starts at the origin but extends to other locations

referred pain

pain that is felt in a location other than where the pain originates

Quality of Pain Descriptors

stabbing, burning, itching, tingling, cramping, aching, dull, tender, shooting, sharp, pressure, crushing, throbbing, etc.

numeric rating scale

patient chooses level of pain for each site 0-10; most adults, but not old

Wong-Baker FACES scale

a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain

PAINAD scale

assessment tool for pain used with dementia patients; assesses 5 common behaviors: breathing, vocalization, facial expression, body language, and consolability. A score of 4 or above indicates a need for pain management.

documentation of pain

Level of pain, description of pain, action taken, response to interventions

OPQRST (pain assessment)

Onset, Provocation, Quality, Region/Radiation, Severity, Timing.

OLDCARTS (pain)

Onset

Location

Duration

Character

Aggravating factors

Relieving factors

Timing

Severity