1. General survey, pain assessment, vital signs

The general survey

a study of the whole person

• discusses general health state and any obvious physical characteristics

• provides an overall impression

• includes objective parameters that apply to the whole body

• includes areas of physical appearance, body structure, mobility, and behavior

Body structure (nutrition): malnutrition

under nourished, impaired an delayed wound/injury healing

Body structure (nutrition): overnutrition

may cause chronic co-morbid health conditions such as diabetes mellitus (DM) type II, hypertension, hyperlipidemia, obesity

Mobility: gait

normally base is as wide as shoulder width

Mobility: foot placement

• accurate; walk smooth, even

• well-balanced; associated movements, such as symmetric arm swing, are present

Mobility: range of motion

note full mobility for each joint, and that movement is deliberate, accurate, smooth, and coordinated

Mobility (gait): spasticity

resistance to passive range of motion (ROM)

Mobility (gait): rigidity/tremor

commonly noted in parkinsons disease

Mobility (gait): myoclonus

muscle jerking, sudden, in setting of seizure

Objective data: measurements weight

• use a standardized balance or electronic standing scale

• instruct person to remove his or her shoes and heavy outer clothing before standing on scale

• when sequence of repeated weights is necessary → aim for approximately same time of day and same type of clothing worn each time

• record weight in kilograms and pounds

• show person how his or her weight matches up to recommended range for height

• compare person’s current weight with previous visit

  • recent weight loss may be explained by successful dieting

  • weight gain usually reflects overabundant caloric intake, unhealthy eating habits, and sedentary lifestyle

Objective data: measurements height

• use a wall-mounted device or measuring pole on scale

• align extended headpiece with top of the head

• person should be:

  • shoeless

  • standing straight

  • looking straight ahead with feet and shoulders on hard surface

Objective data: measurements body mass index (BMI)

practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

Think like a nurse: prioritization

• what is time sensitive and needs to be done STAT?

• what can wait?

• which patient should I see first?

• what and to whom can I delegate?

• nursing handoff report with bedside introduction

Think like a nurse: ABC’s of nursing

• airway

• breathing

• circulation

Think like a nurse: medication administration

• link assessment findings to patients prescribed medications

• what is the patients baseline?

• how will a medication impact the patient’s assessment?

Vital signs: types of pain

• nociceptive

• neuropathic

• cancer pain

Vital signs: two main pathways

nociceptive and/or neuropathic processing

Vital signs (pain): patients present with different types of symptoms

thereby differing in clinical response to therapy

Vital signs (pain): need for accurate pain assessment

better able to develop non-pharmacologic and/or pharmacologic strategies to obtain improved clinical results

Vital signs (pain): nociceptive

+ functional and intact nerve fibers of the peripheral nervous system (PNS) and central nervous system (CNS)

Nociceptive: nociception phases

• 1 transduction

• 2 transmission

• 3 perception of pain

• 4 modulation

Nociception phases: 1 transduction

• injured tissue releases chemicals that propagate pain message

• action potential moves along an afferent fiber to the spinal cord

Nociception phases: 2 transmission

the pain impulse moves from the spinal cord to the brain

Nociception phases: 4 modulation

neurons from brainstem release neurotransmitters that block the pain impulse

Types of pain: neuropathic

• associated with lesion or pathology/ailment of the somatosensory nervous system

• difficulty to assess

• commonly described by patients as so-called pins and needles or numbness/tingling

• indicates type of pain that does not adhere to typical phases inherent in nociceptive pain

• pain due to a lesion or disease in the somatosensory system

• conditions that may lead to development

  • diabetes mellitus, herpes zoster (shingles), HIV/AIDS/ sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy

Neuropathic pain: diagnosis

• sustained on a neurochemical level that cannot be identified by x-ray, computerized axial tomography (CAT) scan, or magnetic resonance imaging (MRI)

• electromyography and nerve-conduction studies are needed

• the abnormal processing of neuropathic pain impulse can be continued by peripheral or central nervous system

Neuropathic pain: proposed mechanisms

• spontaneous and repetitive firing of nerve fibers, almost seizure like in activity

• “neuronal wind-up”

• minor stimuli can lead to significant pain

Vital signs: pain

• the so-called 5th vital sign

• several scales

• what the patient reports it is

Pain: several scales

are used to assess pain

• numeric scale with faces scale

Initial pain assessment questions (qualify all information in the patient’s own words): do you have pain?

discomfort, soreness or “ouch”

Initial pain assessment questions (qualify all information in the patient’s own words): where is your pain?

tell me about all of the places that have pain

Initial pain assessment questions (qualify all information in the patient’s own words): when did your pain start?

• what were you doing when the pain started?

• is it constant or does it come and go?

Initial pain assessment questions (qualify all information in the patient’s own words): what does your pain feel like?

• burning, stabbing, aching

• throbbing, fire like, squeezing

• cramping, sharp, itching, tingling

• shooting, crushing, sharp, dull

Initial pain assessment questions (qualify all information in the patient’s own words): what makes your pain better or worse?

• include behavioral, pharmacologic, and non-pharmacologic interventions

• what medications control your pain? are doses adequate?

• how often to you take pain medication?

Initial pain assessment questions (qualify all information in the patient’s own words): how does pain limit your function or activities?

what does pain prevent you from doing?

Initial pain assessment questions (qualify all information in the patient’s own words): how do you usually react when you are in pain?

• any other symptoms along with the pain?

• how would others know you are in pain?

• is it constant or does it come and go?

Initial pain assessment questions (qualify all information in the patient’s own words): what does pain mean to you?

why do you think you are having pain?

Vital signs pain sources: visceral

• originates within large internal organs

• described as dull, deep cramping

• ex: appendicitis

Vital signs pain sources: somatic

• originates in muscle, bone, tendon, ligament

• described as throbbing, achy

• ex: distal radius fracture (broken wrist bone)

Vital signs pain sources: cutaneous

associated with the surface of the skin, superficial layer

Vital signs pain sources: referred

pain felt in one location yet originates somewhere else in the body

Pain sources based on their origin: visceral pain

originates from larger interior organs

• stems from direct injury to organ or from stretching of organ from tumor, ischemia, distention, or severe contraction

• pain impulse transmitted by ascending nerve fibers along with nerve fibers of autonomic nervous system

• presents with autonomic responses such as vomiting, nausea, pallor, and diaphoresis (sweating)

Pain sources based on their origin: deep somatic pain

comes from sources such as blood vessels, joints, tendons, muscles, and bone

• injury may result from pressure, trauma, or ischemia

• described as aching and throbbing

• usually well localized and able to be identified

• like visceral pain it can be accompanied by nausea, sweating, tachycardia, and hypertension

Pain sources based on their origin: cutaneous pain

derived from skin surface and subcutaneous tissues

• injury is superficial, with a sharp, burning sensation

Pain sources based on their origin: referred pain

felt at a particular site that originates from another location

• both sites are innervated by same spinal nerve, difficult for brain to differentiate point of origin

• may originate from visceral or somatic structures

• various structures maintain their same embryonic innervation

• it is useful to have knowledge of areas of referred pain for diagnostic purposes

Pain timeline: acute

less than 6 months

Pain timeline: chronic

greater than 6 months

PQRST mnemonic

• provocation/palliation

• quality

• region

• severity

• timing

Vital signs: pain receptors

• mu opioid receptors

• opioids may cause effect of pain relief (analgesia) as well as feeling of euphoria

• opioid overdose may cause lethargy, respiratory depression, constipation, potential for death

• patients may develop tolerance to drug therapy involving opioids

  • how would you describe the concept of tolerance

Objective data (vital signs): includes..

• temperature

• respiratory rate

• pulse

• blood pressure

• pain, so called 5th sign

Objective data: vital signs

• trend data across patient encounters in multiple clinical practice settings

• use nursing judgement to warrant additional assessment

• NOTE:

  • vital signs are VITAL for a reason

  • NOT “casual signs”

Assessment techniques

least invasive → most invasive

• Inspection

• Auscultation

• Palpation (light and deep)

• Percussion

Prior to obtainment of vital signs: provide privacy for the patient

if any guests accompany the patient, inquire about the patient’s preference for guest presence during the vital sign check and nursing assessment

Prior to obtainment of vital signs: hand hygiene (handwashing)

• 20 second + scrub using soap and water

• alcohol-based sanitizer for hands with no notable soiling

• always perform hand hygiene upon entrance into as well as exiting the patient environment (room)

Temperature: normal temperature readings in resting person

37C (98.6F), with a range of 35.8C to 37.3C(96.4F to 99.1F)

Temperature: normal temperature readings rectal measures

0.4C to 0.5C (0.7F to 1F) higher

Temperature: normal temperature readings

• oral temperature accurate and convenient

• oral sublingual site has rich blood supply from carotid arteries that quickly responds to changes in inner core temperatures

Temperature: routes of measuring temperature

• axillary

• oral

• rectal

• temporal

• tympanic

Temperature: hypothermia

temp decreased below a normal range

Temperature: normothermia

normal temp

Temperature: hyperthermia (pyrexia)

temp greater than 100.7F

Temperature: what is the term for the body maintaining normal biological functions?

homeostasis

Temperature: what is the term for maintenance of temperature within a normal range in the human body?

thermoregulation

Vitals signs: pulse

palpable flow felt in periphery due to pressure wave generation from stroke volume

• provides indicator of rate and rhythm of heartbeat and local data on condition of artery

Pulse: palpation technique

• using pads of first three fingers, palpate radial pulse at flexor aspect of wrist laterally along radius bone until strongest pulsation is felt

• assess pulse for rate, rhythm, force, and elasticity

Pulse palpation technique: if rhythm is regular..

count number of beats in 30 seconds and multiply by 2

Pulse palpation technique: 30-second interval

most accurate and efficient when heart rates are normal or rapid and when rhythms are regular

Pulse palpation technique: for irregular pulse..

count for full minute

Heart rate (pulse): how do you calculate cardiac output?

heart rate (HR) x stroke volume (SV)

Cardiac output defined

amount of blood flow circulated throughout the body in one minute

Heart rate

so-called normal adult range (50-95 beats per minute)

Tachycardia

elevated heart rate above 95+ BPM

Bradycardia

heart rate below 50 BPM

In resting adult, current research indicates normal heart rate range is 50 to 95 BPM: rate normally varies with age

more rapid in infancy and childhood and moderate during adult and older years

In resting adult, current research indicates normal heart rate range is 50 to 95 BPM: rate also varies with gender;

after puberty, females have slightly faster rate than males

Heart rate: in adults..

less than 50 BPM is bradycardia

• occurs normally in well-trained athletes whos heart muscle develops long with skeletal muscles

Normal heart rate range is 50 to 95 BPM, stronger, more efficient heart muscle pushes out a larger stroke volume with each beat →

thus requiring fewer beats per minute to maintain stable cardiac output

Heart rate: tachycardia

occurs normally with anxiety or with increased exercise → to match body’s demand for increased metabolism

Heart rhythm

rhythm of pulse normally has a regular, even tempo

• if any irregularities are felt → auscultate heart sounds for a more complete assessment

Heart rhythm: sinus arrhythmia

one irregularity common found in children and young adults

Heart force: strength of pulse

force of pulse is strength of hearts stroke volume

Heart force strength of pulse: weak..

thready pulse reflects a decreased stroke volume

ex: as occurs with hemorrhagic shock

Heart force strength of pulse: full..

bounding pulse denotes increased stroke volume, as with anxiety, exercise, and some abnormal conditions

Heart force: pulse force recorded using three-point scale

3+ full, bounding

2+ normal

1+ weak, thready

0 absent

Heart rate (pulse): if pulse difficult to grade/palpate/assess →

consider evaluation and assessment using ultrasound doppler machine

• place petroleum jelly on doppler probe and apply with slight force to patients pulse site

• listen carefully for audible sound

Respiratory rate: normal rate for healthy adult

12-20 breaths per min

Tachypnea

breathing faster than 20+ breaths per min

Bradypnea

breathing slower than 12 breaths per min

Respiratory rate: factors influencing respiratory rate

• pain

• stress or anxiety

• exercise

• infection

• medications (drug therapy)

• injury (neurologic or otherwise)

• other

Blood pressure (BP)

the force of blood pushing against side of its container, vessel wall

• strength of push changes with event in cardiac cycle

Blood pressure (BP): systolic pressure

maximum pressure felt on artery during left ventricular contraction, or systole

Blood pressure (BP): diastolic pressure

elastic recoil, or resting, pressure that blood exerts constantly between each contraction

Blood pressure (BP): pulse pressure

difference between systolic and diastolic blood pressure

• reflects stroke volume

Blood pressure (BP): mean arterial pressure (MAP)

pressure forcing blood into tissues, averaged over cardiac cycle

Blood pressure (BP): normal adult blood pressure

120/80 mmHg

Blood pressure factors: cardiac output

increase in CO leads to increase in BP whereas decrease in CO leads to decrease in BP

Blood pressure factors: peripheral vascular resistance

increased resistance (vasoconstriction) leads to increase in BP

• decrease in resistance (vasodilation) leads to decrease in BP

Blood pressure factors: volume of circulating blood

fluid retention leads to increased BP whereas hemorrhages leads to decreased BP

Blood pressure factors: viscosity

increase associated with increase in BP

Blood pressure factors: elasticity of vessel walls

increasing rigidity associated with increase in BP