Module b knowt

General Survey

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