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General Survey
A comprehensive assessment of a patient's overall appearance, including vital signs.
Vital Signs
Measurements of the body's most basic functions including temperature, pulse, respiration, blood pressure, and pain.
Inspection
A technique in physical examination which involves visually assessing the patient.
Palpation
The method of feeling with the hands during the physical examination.
Auscultation
Listening to the internal sounds of the body, typically with a stethoscope.
Physical Presence Indicators
Includes build, personal hygiene, stated age versus apparent age, body fat, and mood.
Height and Weight
Important components of the general survey used to assess growth and nutritional status.
Thermoregulatory Center
Located in the hypothalamus, it regulates body temperature.
Signs that Vital Signs Should Be Assessed
On admission, changes in condition, before and after surgery, or medication affecting heart/lung function.
Normal Oral Temperature Range for Healthy Adults
96.4-99.5°F.
Factors Affecting Body Temperature
Circadian rhythms, age, gender, physical activity, state of health, and environmental temperature.
Heat Loss Mechanisms
Includes skin evaporation, warming inspired air, and elimination of urine and feces.
Sites for Assessing Temperature
Tympanic membrane, oral, rectal, axillary, temporal.
Electronic Thermometers
Devices for measuring body temperature quickly and accurately.
Normal Pulse Rate for Adults
60 to 100 beats per minute, with an average of 80.
Eupnea
Normal, unlabored respiration.
Apical Pulse Location
Between the 5th and 6th rib at left midclavicular line.
Pain Definition
Whatever the patient says it is, influenced by biologic, psychological, and social factors.
Gate Control Theory of Pain
Describes the relationship between pain and emotions, explaining how some nerve fibers inhibit pain.
PQRST Method for Pain Assessment
A tool to evaluate pain: Provokes, Quality, Radiates, Severity, Time.
Acute Pain Characteristics
Rapid onset, protective nature, varies in intensity and duration.
Chronic Pain Characteristics
May persist beyond normal healing, intermittent, or persistent with periods of remission.
Factors Affecting Respirations
Include exercise, disease, fluid balance, medications, and emotional factors.
Systolic Pressure Definition
The highest arterial pressure during contraction of the heart's ventricles.
Diastolic Pressure Definition
The lowest arterial pressure during relaxation of the heart's ventricles.
Blood Pressure Measurement Tools
Stethoscope, sphygmomanometer, Doppler ultrasound, and electronic devices.
Signs of Hypotension
Blood pressure <90/60 mm Hg, can indicate disease or medications affecting pressure.
Orthostatic Hypotension
Low blood pressure when standing, resulting from inadequate physiological responses.
Characteristics of Peripheral Pulse
Rate (normal/tachycardia/bradycardia), amplitude, rhythm, and stroke volume.
Qualities of Respiration
Includes depth, rhythm, and any abnormal breathing patterns such as tachypnea or bradypnea.
Pain Assessment Indicators
Patient's description, location, duration, quantity/intensity, and quality of pain.
Complementary Health Approaches
Methods to relieve pain like distraction, music, and mindfulness.
Primary Sources of Heat
Metabolism is the primary mechanism affecting body temperature.
Pulse Measurement Technique
Locate the pulse, adjust pressure, count for 30 seconds, and count for a full minute if irregular.
Pain Process Stages
Transduction, transmission, perception, and modulation of pain.
Behavioral Responses to Pain
The observable reactions of a patient indicating they are in pain.
Emotional Factors Affecting Pain
Anxiety, past experiences, and cultural variances can influence a person's pain experience.
Vagal Stimulation Effect on Heart Rate
Parasympathetic impulses slow the heart rate.
Renin-Angiotensin-Aldosterone System
Hormonal system that increases blood pressure.
Temperature Assessment Tools
Types of thermometers used to measure body temperature accurately.
Respiration Measurement Guidelines
Do not inform the patient you are counting their respirations.
Pain Severity Scale
A rating from 1 to 10 indicating how severe the pain feels.
Factors Affecting Blood Pressure Measurements
Includes factors like age, race, and health status.
Assessing Blood Pressure Technique
Listening for Korotkoff sounds to determine systolic and diastolic pressure.
Thermal Regulation Responses
Hypothalamus initiates responses to conserve or dissipate heat.
Pain and Nociception
Pain is more than nociception; it is a personal experience influenced by many factors.
PQRST Pain Assessment - Provokes
Understanding what causes the pain and what alleviates or worsens it.
PQRST Pain Assessment - Quality
Describing the nature of the pain, whether it is sharp, dull, or burning.
PQRST Pain Assessment - Radiates
Determining if the pain spreads to other areas or is localized.
Nursing Interventions for Pain Management
Include building trust, complementary approaches, and legal responsibilities.
Basic comfort and care
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