HA PRELIMS WEEK 2

GENERAL STATUS SURVEY

-            is the first part of the physical examination and begins the moment the nurse meets the client.

-            It provides an overall impression of the client’s whole being.

-            Observations to make:

o   Physical development and body build

o   Gender and sexual development

o   Apparent age compared to reported age

o   Skin condition and color

o   Dress and hygiene

o   Posture and gait

o   Level of consciousness

o   Behaviors, body movements, and affect

o   Facial expression

o   Speech

o   Vital Signs

VITAL SIGNS

-            (Pulse, Respirations, Blood Pressure, Temperature, and Pain) are the body’s indicators of health.

TEMPERATURE

-            Normal Core Body Temperature: 36.5°C – 37.7°C (96.0°F – 99.9°F)

-            Methods & Normal Ranges:

METHOD / ROUTE	NORMAL RANGE	PROCEDURE	INDICATIONS
Oral	35.9°C – 37.5°C (96.6°F – 99.5°F)	Place thermometer under the tongue to the right or left of the frenulum, deep in the posterior sublingual pocket.	• Sublingual area rich in blood vessels ❌ Not for patients with seizures ❌ Not for unconscious patients
Tympanic (Ear)	36.7°C – 38.3°C (98.0°F – 100.9°F)	Place probe gently at the opening of the ear canal for 2–3 seconds.	• Measures temperature near the eardrum • Close to hypothalamus (core control center) • Good for toddlers
Axillary (Armpit)	35.4°C – 37.0°C (95.6°F – 98.5°F)	Place thermometer in the axilla with arm held snugly against the body.	• Measures body heat released ✔ Infants ✔ Cooperative adults ✔ Sleeping patients • Usually 0.5°C (1°F) lower than oral
Temporal (Forehead)	36.3°C – 37.9°C (97.4°F – 100.3°F)	Scan thermometer across the forehead/temporal artery.	✔ Sleeping patients ✔ Large group screening • Approximately 0.4°C (0.8°F) higher than oral
Rectal	36.3°C – 37.9°C (97.4°F – 100.3°F)	Insert thermometer gently into the rectum; never force.	• Closest to core temperature • Use only if other routes are not practical ❌ Hemorrhoids ❌ Low platelet count patients ❌ Neutropenic patients

ORAL
TYMPANIC
AXILLARY
TEMPORAL
RECRAL

ROUTE FOR GETTING TEMPERATURE

ORAL

35.9°C – 37.5°C (96.6°F – 99.5°F)

Place thermometer under the tongue to the right or left of the frenulum, deep in the posterior sublingual pocket.

• Sublingual area rich in blood vessels ❌ Not for patients with seizures ❌ Not for unconscious patients

TYMPANIC

36.7°C – 38.3°C (98.0°F – 100.9°F)

Place probe gently at the opening of the ear canal for 2–3 seconds.

• Measures temperature near the eardrum • Close to hypothalamus (core control center) • Good for toddlers

AXILLARY

35.4°C – 37.0°C (95.6°F – 98.5°F)

Place thermometer in the axilla with arm held snugly against the body.

• Measures body heat released ✔ Infants ✔ Cooperative adults ✔ Sleeping patients • Usually 0.5°C (1°F) lower than oral

TEMPORAL

36.3°C – 37.9°C (97.4°F – 100.3°F)

Scan thermometer across the forehead/temporal artery.

✔ Sleeping patients ✔ Large group screening • Approximately 0.4°C (0.8°F) higher than oral

RECTAL

36.3°C – 37.9°C (97.4°F – 100.3°F)

Insert thermometer gently into the rectum; never force.

• Closest to core temperature • Use only if other routes are not practical ❌ Hemorrhoids ❌ Low platelet count patients ❌ Neutropenic patients

PULSE

-            Definition: A shock wave produced when the heart contracts and pumps blood out of the ventricles into the aorta.

-            How to Palpate: Use the pads of your two middle fingers and lightly palpate the radial artery on the lateral aspect of the client’s wrist.

-            Normal Rate: 60–100 beats/min (Adults).

-            What to Assess: Rate, Rhythm, Amplitude (0 to 3+ scale), and Elasticity.

GRADE	DESCRIPTION	CLINICAL SIGNIFICANCE
0 (Absent)	Unable to palpate pulse	Cardiac arrest, shock, clot
1+ (Weak / Diminished)	Easy to obliterate with light pressure	Weak heart, hypovolemia, dehydration
2+ (Normal)	Obliterates with moderate pressure	Normal finding
3+ (Bounding)	Unable to obliterate or requires firm pressure	Sepsis, fever, wide pulse pressure, anxiety, pregnancy

RESPIRATIONS

-            Normal Rate: 12–20 breaths/min.

o   bpm – breaths/min

o   cpm – cycles/min

-            How to Measure: Observe the client’s chest rise and fall with each breath. Count for 30 seconds and multiply by 2.

o   Tip: Monitor without alerting the client (e.g., keep fingers on the pulse site while counting respirations) to prevent the client from altering their breathing pattern.

BLOOD PRESSURE

-            Definition: The pressure exerted on the walls of the arteries.

-            Apparatus Used: Sphygmomanometer (aneroid, mercury, or electronic) and Stethoscope.

-            Normal Values:

o   Systolic: < 120 mmHg

o   Diastolic: < 80 mmHg

SPHYGMOMANOMETER

Apparatus Used in Getting Blood Pressure

PREPARATION FOR GETTING BLOOD PRESSURE

-            To get an accurate reading, you must eliminate factors that cause temporary BP spikes.

-            The Environment: Room should be quiet and comfortable (not too hot/cold).

-            The Client:

o   Must rest for 5–10 minutes before the test.

o   NO: Recent exercise, smoking (nicotine), alcohol, or a full bladder.

o   NO: Talking during the measurement (by you or the client).

o   Legs: Uncrossed and feet flat on the floor.

CUFF SELECTION

-            Using the wrong size causes errors.

-            The Rule: The rubber bladder inside the cuff should wrap around 80% of the arm.

o   Too Small/Tight: = False HIGH reading.

o   Too Large/Loose: = False LOW reading.

POSITIONING
PLACEMENT
ESTIMATION
MEASUREMENT
LISTENING

Steps for BP Measurement

POSITIONING

Posture: Client sits with back supported, legs uncrossed.

Arm: Upper arm exposed (remove tight clothing), supported at. HEART LEVEL, palm facing up

PLACEMENT

Apply Cuff: Wrap cuff snugly about 1 inch (2.5 cm) above the bend of the elbow (antecubital area).

Align: Ensure ARTERY MARKER on the cuff aligns with the BRACHIAL ARTERY

ESTIMATION (PALPATORY METHOD)

Purpose: Ensures you pump high enough and do not miss the systolic (top) number.

Palpate radial or brachial pulse.

Inflate cuff until pulse disappears

Note the number and ADD 30 mmHg → TARGET INFLATION PRESSURE.

MEASUREMENT (AUSCULTATORY METHOD)

Place stethoscope lightly over the brachial artery.

Inflate cuff to the target number from Step C.

Deflate SLOWLY at 2 mmHg per second.

LISTENING (KOROTKOFF SOUNDS)

SYSTOLIC (Top Number): First clear tapping sound (Phase I).

DIASTOLIC (Bottom Number): Sound disappears completely (Phase V).

Deflate fully and remove cuff.

PULSE PRESSURE

-            Computation: Systolic BP minus Diastolic BP (Example: 120 − 80 = 40 mmHg)

-            Normal Range: 30–50 mmHg

OXYGEN SATURATION

-            Normal Values: 95 – 100%

-            Measurement: Can be measured using a mobile monitoring system (e.g., “DINAMAP”) or Pulse Oximeter which often includes an oxygenation saturation detector.

PAIN

-            is a universal experience but is unique to every individual.

-            It is considered the “Fifth Vital Sign” and should be assessed with the same vigilance as temperature, pulse, respiration, and blood pressure.

o   Primary Definition (Margo McCaffery): “_____ is whatever the experiencing person says it is, existing whenever he or she says it does.”

o   Technical Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

TRANSDUCTION
TRANSMISSION
PERCEPTION
MODULATION

4 process of pain detection (Nociception)

TRANSDUCTION

The conversion of a noxious (painful) mechanical, thermal, or chemical stimulus into an electrical signal (action potential) by nociceptors (nerve endings).

TRANSMISSION

The pain signal travels from the peripheral nerves to the spinal cord and then to the brain.

PERCEPTION

The brain recognizes, defines, and responds to pain — this is when the person becomes aware of the pain.

MODULATION

The body’s natural attempt to inhibit or alter pain impulses, such as through the release of endorphins.

ACUTE PAIN
CHRONIC PAIN
CANCER PAIN

Types of Pain By Duration/Etiology

ACUTE PAIN

Short-term, usually less than 6 months

Recent injury or surgery

Associated with “fight-or-flight” response → increased HR and BP; client often appears anxious or restless

CHRONIC PAIN OR NONMALIGNANT PAIN

Persistent, lasts more than 6 months

Arthritis, fibromyalgia, back pain

Body adapts to pain; vital signs often normal; client may appear depressed or withdrawn rather than anxious

CANCER PAIN

May be acute or chronic

Compression of peripheral nerves or meninges due to tumor growth, surgery, chemotherapy, or radiation

Often progressive and may require aggressive pain management

CUTANEOUS PAIN
VISCERAL PAIN
DEEP SOMATIC PAIN
RADIATING PAIN
REFERRED PAIN
PHANTOM PAIN

TYPES OF PAIN BY LOCATION/SOURCE

CUTANEOUS PAIN

Skin or subcutaneous tissue

Sharp, burning pain (e.g., paper cut, burn)

VISCERAL PAIN

Abdominal cavity, thorax, cranium

Often vague, dull, or cramping (e.g., menstrual cramps, appendicitis)

DEEP SOMATIC PAIN

Ligaments, tendons, bones, blood vessels, nerves

Achy and tender (e.g., ankle sprain, fracture)

RADIATING PAIN

Originates at a source and extends to other tissues

Pain is felt at the source and along the path

REFERRED PAIN

Perceived away from the actual pain source

(e.g., left arm pain in myocardial infarction, shoulder pain from gallbladder disease)

PHANTOM PAIN

Nerves of a missing, amputated, or paralyzed body part

Pain is perceived despite absence of the body part

NEUROPATHIC PAIN
BOCICEPTIVE PAIN

TYPES OF PAIN BY CAUSE

NEUROPATHIC PAIN

Abnormal processing of pain messages due to damage to the nerves

Diabetic neuropathy, shingles

Burning, shooting, electric-shock-like

NOCICEPTIVE PAIN

Normal response to damage to somatic or visceral tissue

Tissue injury, inflammation

Aching, throbbing, sharp

7 DIMENSIONS OF PAIN

DIMENSION	DESCRIPTION	EXAMPLES
Physical	The patient’s physiologic perception of pain	Bodily sensation of pain
Sensory	The quality of the pain	Severity, location, quality
Behavioral	Verbal and nonverbal behaviors related to pain	Grimacing, guarding, crying
Sociocultural	Influence of social context and cultural background on pain expression	Cultural norms, family influence
Cognitive	Beliefs, attitudes, and memories regarding pain	Pain expectations, past experiences
Affective	Feelings and emotions resulting from pain	Anxiety, fear, depression
Spiritual	Meaning or purpose attributed to the pain	“Is this punishment from God?”

NUMERIC RATING SCALE (NRS)

-            0 (No Pain) to 10 (Worst Possible Pain). Best for cognitively intact adults.

WONG-BAKER FACES SCALE

-            Faces ranging from smiling (0) to crying (10). Best for children and clients with cognitive barriers.

VERBAL DESCRIPTION SCALE

-            Uses words (Mild, Moderate, Severe)

FLACC SCALE

-            Face, Legs, Activity, Cry, Consolability

-            Observational tool used for infants and non-verbal clients.

ITEM	0	1	2
FACE	No particular expression or smile.	Occasional grimace, frown, withdrawn, or disinterested.	Frequent to constant frown, clenched jaw, quivering chin.
LEGS	Normal position or relaxed.	Uneasy, restless, tense.	Kicking or legs drawn up.
ACTIVITY	Lying quietly, normal position, moves easily.	Squirming, shifting back and forth, or tense.	Arched, rigid, or jerking.
CRY	No cry.	Moans, whimpers, or occasional complaint.	Crying steadily, screams or sobs, frequent complaints.
CONSOLABILITY	Content, relaxed.	Reassured by occasional touching, hugging, or being talked to, distractible.	Difficult to console or comfort.

PATIENT BARRIERS
PROVIDER BARRIERS

BARRIERS TO PAIN ASSESSMENT

PATIENT BARRIERS

-            Fear of addiction to pain medication.

-            Belief that pain is a normal part of aging.

-            Desire to be a “good” patient (not complaining).

PROVIDER BARRIERS

-            Failure to believe the client’s report (Subjectivity).

-            Focusing only on vital signs.

-            Time constraints.

-            Personal bias regarding drug-seeking behavior.

STOIC CULTURES

-            May value self-control and hide pain; may not report pain unless asked directly.