301 : GENERAL SURVEY

Why should a nurse document any “body system issues” during a quick overall assessment (observation) of a client?

The nurse should note any issues with the client’s body system because that will require a more FOCUSED assessment.

TRUE OR FALSE: A quick overall assessment a.k.a observation begins the moment you meet/greet the client.

true

How could a nurse establish trust and build rapport with a client?

therapeutic communication

What are the two types of THERAPEUTIC COMMUNICATION?

verbal communication and nonverbal communication

What does VERBAL COMMUNICATION consist of?

be aware of what kind of words you use, and how you present these words

How would a nurse engage in VERBAL COMMUNICATION with a patient?

the nurse should be engaging in active listening, expressing empathy, being respectful, and showing acceptance of the patient and their situation

What does NONVERBAL COMMUNICATION consist of?

★ communication using your body language

★ ex. eye contact, posture, touch, facial expression, gestures, physical proximity, and orientation toward the client

How would a nurse engage in NONVERBAL COMMUNICATION with a patient?

★ communicates warmth, interest, and availability.

★ maintains a four-to-five-foot therapeutic distance to respect personal space is acceptable

★ sit at the client's eye level while making eye contact

★ maintain a calm and relaxed posture; use gestures, such as nodding, and display a pleasant facial expression.

How would MISCOMMUNICATIONS occur between a nurse and a patient?

may occur due to cultural or personal reasons, past experiences, or current \n emotional/physical state

During a GENERAL SURVEY, what is the initial checklist/tasks a nurse should be aware of? ( HINT: 2★)

★ observe the client's appearance, behavior, body structure, and mobility
★ note anything that the client may be experiencing abuse, neglect, or human trafficking
★ general appearance
★ behavior
★ mood/state of emotion

How would you assess the GENERAL APPEARANCE of a client?

★ its a quick overall assessment
★ note any signs of acute distress
★ apparent relative to the stated age
★ look for any abnormalities in skin color and integrity
★ movement and symmetry of facial features
★ level of consciousness related to alertness and orientation to person, place, and time

LEVEL F CONSCIOUSNESS is related to what?

alertness and orientation

What is the difference between orientx3 vs oriented x4? \*wait idk if this one is correct

★ orient x3 means that the client knows who the are (person), where they are (place), and can identify the time

★ orient x4 is the same as orient x3 but the patient is also aware of their situation (hence the x4)

How would you assess the BEHAVIOR of a client?

★ observation of client's speech, mood , and affect (clear, articulate, understandable)
★ coherent thoughts
★ speech evenly paced
★ client pleasant and cooperative
★ facial expressions and mood consistent with situation
★ client appropriately dressed and groomed for weather and situation

How would you assess the MOOD of a client?

★ mood is a state of emotion that is expressed verbally and nonverbally
★ ask yourself, " is the mood appropriate with the client's condition"

What is a patient's AFFECT? How would you assess the AFFECT of a client?

★ physical expression of the client mode or how the client's mood appears to others
★ ask yourself, " does the client's affect correlate with the client's stated mood?

How do you assess if a client is being abused, neglected or involved with human trafficking.

★ any signs the clients may be experiencing abuse (ex. a bruise, neglect, intimate partner violence, or human trafficking \[ sexual or labor\])
★ unkempt or inappropriate/ dirty clothing
★ appears malnourished or dehydrated
★ difficulty walking or sitting due to perineal or rectal pain
★ physical injuries without adequate explanation or overly attentive companion who answers all questions

How can you assess a client's BODY STRUCTURE ?

★ Observe the client's posture & positioning
★ are there any observable body alterations?
★ are the body parts symmetrical and proportionate?

How can you assess a client's MOBILITY?

★ focuses on gait and range of motion
★ note the ability to move each joint and walk
★ identify any involuntary movements

What kind of MEASUREMENTS do you need to obtain during a general survey?

clients height & weight

Why should we note the ANTHROPOMETRIC MEASUREMENT in relationship to age?

anthropometry refers to the measurement of the human individual, therefore you are just checking if a client’s height and weight is accurate for their age group

What are VITAL SIGNS? What do you document for vitals?

★ baseline assessment

★ note route of temperature, rhythm, rate, and strength of pulse

During a general survey, pain involves observation of nonverbal cues like what? What is a mnemonic to help you remember?

★ examples like grimacing, bracing, guarding
★ PQRST & COLDSPA

How do you assess a client's EMOTIONAL state?

through an assessment of behaviors and statements

How do you assess a client's eye contact?

★ Assess patient’s amount of eye contact while considering client's \n cultural background

★ note when eye contact is established then lost due to changes in questions and answers (non-sensitive to sensitive questions)

→ EX. asking “do you feel safe in your home environment” & patient has a change in eye contact & body language.

What is LOC?

level of consciousness

How would you determine a client’s level of consciousness (LOC)?

Ask yourself, “Is the client alert and oriented to person, place, time, and situation?”

FILL IN THE BLANK: ________________ has acute confusion that comes and goes.

delirium (this is a unexpected finding for LOC)

FILL IN THE BLANK: ____________ has chronic, progressive confusion.

dementia (this is a unexpected finding for LOC)

What does LETHARGIC mean?

★ not fully awake
★ we'll drift off to sleep with lack of interaction or stimulation and are easily awakened With calling of name or verbal stimulation.

What does OBTUNDED mean?

★ asleep and only arouses with loud auditory or physical stimulation
★ confused and speaks in one-word sentences when awake and falls back asleep without constant stimulation.

What does STUPOR mean?

unconsciousness but will respond to physical stimuli or pain with movement or incoherent vocalizations.

What does COMATOSE mean?

completely unconscious and has no response to physical or painful stimuli.

How do you assess a client's SKIN?

★ ensure the skin is warm to touch , dry, and intact with even skin tones - versus cool, hot, diaphoretic, or clammy skin.
★ color abnormalities may include areas of uneven skin tone, pallor, cyanosis, jaundice, erythema, or notation of any obvious lesions.

How do you assess a client's PERSONAL HYGIENE?

★ observe clients grooming, noting body and breath odors and inspecting dental hygiene
★ Be performed when nurse is involved in closer contact with the client such as obtaining vital signs.
★ Be aware it varies among cultures, socioeconomic classes, and occupations.

How do you assess GROOMING?

★ assess clients clothing, hair, and nails determine if causing and hair are clean, appropriate, and fitting for the weather.

★ ex. odor - Overt ( done or shown openly) and body odor are noted.

How do you assess ODOR?

Overt breath and body odor are noted.

TRUE OR FALSE: Depending on the visit, circumstance, or reason for seeking care, a client's height, weight, BMI, and waist circumference are part of the initial survey.

true

VITAL SIGNS include what?

temperature, pulse, respiration, blood pressure, pulse oximetry, and pain

Why is collecting VITAL SIGNS important?

★ assess the effectiveness of the client circulatory, neurological, endocrine, and respiratory systems

★ provides baseline data regarding the client's health status

★ frequency with which you measure vital signs is based on the stability of the patient.

How is TEMPERATURE regulated?

regulated through a balance of heat production , conservation, and loss core

What is the normal range for TEMPERATURE?

temperature ranges between 36 degrees Celsius and 38 degrees Celsius (96.8 - 100.4 degrees F)

What is the average degree for TEMPERATURE?

average 37 degrees Celsius (98.6F).

RECTAL and TEMPORAL is usually how many degrees higher than oral?

rectal and temporal is usually 1 degree Fahrenheit higher than oral

What is the difference between AXILLARY and TYMPANIC temperatures compared to ORAL temperatures? (HINT: how far off is the temperature?)

Axillary it's usually 1 degree Fahrenheit lower than oral , while tympanic is consistent with oral.

Before taking someone's temperature ORALLY, what should you consider?

★ ensure the client has not smoked or had oral intake recently

★ the patient should be able to follow commands when taking oral temperatures.•

What is considered the most accurate reading of core temperatures?

rectal

If rectal temperature the most accurate, why is it not used more often

because it is invasive, time consuming, increases the risk of transmission of infection, and may be uncomfortable.

Before taking someone's RECTAL temperature, what should you consider?

the anus is not self-lubricating, apply water soluble jelly prior to insertion

Rectal temperatures are contraindicated (not suggested) for clients who have what?

clients who have rectal bleeding, diarrhea, rectal disorders, rectal surgery, or oncology patients.

Before taking someone's TEMPORAL temperature , what should you consider?

the probe should be held at the center of the forehead then moved across the forehead than behind the ear to obtain and accurate temperature.

Which temperature route is considered less accurate and is used less often in adults.

axillary

Before taking someone's TYMPANIC temperature , what should you consider?

★ quick, easily accessed, and reflects a core temperature ,

★ accuracy can be impacted of the patient is lying on the side of the scan, cerumen being present, pathologic variances or infection present in the ear.

★ proper tympanic temperature technique requires the infrared beam directly aimed at the tympanic membrane.

What could affect a TYMPANIC temperature reading?

★ patient is lying on the side of the scan

★ cerumen being present

★ pathologic variances or infection present in the ear.

Why do we take a patient's pulse?

★ offers information regarding the circulatory and cardiac status of the client

★ nurse may determine heart rate, rhythm, and strength of contractions.

What does the palpable pulsation result from?

contraction of the heart and blood flow through the peripheral arterial system.

TRUE OR FALSE: Equality of pulses maybe determine by palpating the same pulse site on the left and right side of the body.

true

List the pulse points on the body.

temporal, carotid, brachial, radial/ulnar, femoral , popliteal, posterior tibialis/dorsalis pedis (pedal pulses)

What are the most commonly checked pulse points?

radial pulse and pedal pulses

If the client is unstable or has a poor cardiac output, which pulse point are commonly checked?

apical and carotid pulses

TRUE OR FALSE: If a nurse found a brisk pulse (2+) at the most distal locations from the heart, under normal conditions, the pulse points closer to the heart would have the same brisk pulse.

true! ( okay i’ve asked hess this before, but im still confused. this is a general rule of thumb, but there will be scenarios where the pulse points at different locations will have different pulse points. but ig for textbook purposes, all pulse points will usually be the same.)

How do you assess a client's PULSE quality?

when assessing a pulse determine

→ the pulse rate (number of pulsations in one minute)

→ rhythm (regularity) of the pulse

\
\*\* note if the rate is within the EXPECTED REFERENCE range for the client based on their AGE

What is the average pulse rate for an adult/older adult at rest?

heart rate is between 60 and 100 beats per minute

What is the average pulse rate for an adolescence at rest?

50 to 90 beats per minute

TRUE OR FALSE: The rhythm does not need regular and consistent intervals between each pulsation.

false, The rhythm should be regular and consistent intervals between each pulsation.

TRUE OR FALSE: The rhythm that is irregular is an unexpected finding.

true

Chris Evans noted that his client’s heart rate had a consistent irregular rhythm. How could an irregular rhythm be consistent?

the client’s pulse is skipping every 4th beat

What does it mean if a patient’s heart rate is IRREGULARLY IRREGULAR?

there is no consistency to the patient’s heart rate

Ryan Reynolds came across an unexpected finding in his client. during his general survey, he notice that his patient's heart rate is irregular. An irregular heart rate is referred to as what?

dysrhythmia or arrhythmia

Ryan Reynolds came across an unexpected finding in his client. during his general survey, he notice that his patient's heart rate is irregular. What should he do next?

Determine whether the irregular rhythm is consistent (such as the pulse skipping every 4th beat) or if there is no consistency to the rhythm.

How do you assess a patient's PULSE STRENGTH?

★ assess the strength or amplitude of the pulse.

★ Pulse strength is measured on a scale of 0 to +4

★ 0 = And absent, impalpable pulse

★ +1 = A weak, thready, diminished pulse

★ +2 = a normal, brisk pulse (expected finding)

★ +3 = and increased, strong pulse

★ +4 = A bounding, full volume pulse

What determines the PULSE STRENGTH?

the strength of the pulse reflex the force of the heart contractions, the volume of blood ejected, and the flow of blood to the pulse site

A pulse strength of 0 indicates what?

An absent, impalpable pulse

A pulse strength of 1+ indicates what?

A weak, thready, diminished pulse

A pulse strength of 2+ indicates what?

a normal, brisk pulse (expected finding)

A pulse strength of 3+ indicates what?

an increased, strong pulse

A pulse strength of 4+ indicates what?

A bounding, full volume pulse

How do you know a pulse's EQUALITY?

the pulse is normally equal bilaterally or symmetrically

TRUE OR FALSE: The radial pulse on the left and right arm should be equal.

true

How do you assess a patient's PULSE OXIMETRY (SPO2)?

★ uses a pulse oximeter( a device that uses a light wavelength to detect the amount of oxygen that is bound to hemoglobin)

★readings are provided as percentages of saturation and estimate the client's arterial oxygen status (Sa02).

★ pulse oximetry provides information regarding the client's respiratory status.

What are some factors that could affect a PULSE OXIMETRY (SPO2) reading ?

★ carbon monoxide poisoning, jaundice, painted or thickened nails, recent injection of dyes into the circulatory system, and dark skin tone

★ client movement during testing and interference from external light sources

★ clients with impaired circulation to include peripheral vascular disease, hypothermia, vasoconstriction, hypotension, and peripheral edema.

What should you check before you assess a patient's OXYGEN SATURATION with a pulse oximeter?

★ inspect the skin, nail beds, and lips for cyanosis

★ also assess the person's breathing for any abnormal rate, rhythm, depth, and sounds

★ assess the client’s behavior for any irritability, restlessness, or confusion (signs of hypoxia)

How do you assess a person's BREATHING?

look for any abnormal rate, rhythm, depth, and sounds

What are some other conditions to note that may alter oxygen saturation readings?

the use of oxygen therapy , bronchodilators, and low hemoglobin levels.

What are RESPIRATIONS?

the exchange of oxygen and carbon dioxide through their processes such as ventilation, diffusion, and perfusion.

TRUE OR FALSE: Breathing is regulated by the brain stem and is an involuntary process.

true

RESPIRATIONS are assessed by which factors?

rate, depth, and rhythm.

What is RESPIRATION RATE?

the amount of breaths (one respiratory cycle = one inspiration and one expiration) per one minute.

What is the normal range for RESPIRATION RATE in adults?

12 to 20 breaths per minute.

How is RESPIRATION DEPTH measured?

★ by an even, quiet, and regular breathing pattern.

★ chest normally moves in and out in a way that is easily observable. ( look at the chest)

What is EUPNEA?

normal breathing ( there shouldn’t be any deep or shallow respirations present)

What is called when there is minimal chest expansion during respirations.?

shallow depth

What is present when the client uses full chest expansion for each breath?

deep respirations

A nurse notes that Tony Starks is taking deep respirations. Since he is attempting to draw in as much air as possible with each breath, his breathing is also considered what?

labored

How do you assess a patient's RESPIRATION RHYTHM?

★ observe the clients respiratory rhythm that has an even rate with a depth consistent with eupnea.

★ rhythm is considered regular or irregular.

What are some factors that affect RESPIRATIONS?

exercise, pain, anxiety, smoking, body position, medications, neurologic injury, alterations in hemoglobin level.

What is the force of pulsing blood on the walls of an artery and is a good indicator of a client's cardiovascular health?

blood pressure (BP)

What is SYSTOLIC PRESSURE?

the peak of the maximum pressure in the arteries that occurs when the heart contracts and pushes blood into the vascular system

What is DIASTOLIC PRESSURE?

the minimum pressure in the arteries that occur when the ventricles of the heart relax, and blood enters the ventricles.

How do you determine an appropriate blood pressure cuff size for a client? Why is this important?

★ it is important to use a blood pressure cuff that is the appropriate size for the client , and will help ensure an accurate reading the length of the bladder within

★ the cuff should cover at least 80% of the circumference of the limb being used

★ the width of the cuff should be approximately 40% of the circumference of the limb.