General Survey - Amy Rangel PDF

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General Survey, Measurement, Vital Signs, & Pain Assessment: Ch4 

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General survey » The general survey is a study of whole person » Covers general health state and any obvious physical characteristics » Does person look sick, rising slowly or with effort, with shoulders slumped and eyes without luster or downcast? » Even as you introduce yourself and shake hands, you collect data A few Objective Data 1. Physical appearance ¨ Age: person appears his or her stated age ¨ Sex: sexual development is appropriate for sex and age ¨ Level of consciousness: the person is alert and oriented, attends to questions, and responds appropriately ¨ Skin color: color tone is even, pigmentation varying with genetic background; skin is intact with no obvious lesions ¨ Facial features: features are symmetric with movement ¨ ** There are no signs of acute distress ** 2. Body structure ¨ Stature: the height appears within normal range for age and genetic heritage ¨ Nutrition: the weight appears within normal range for height and body build.  Body fat distribution is even ¨ Symmetry: body parts look equal bilaterally and are in relative proportion to one another ¨ Posture: the person stands comfortably erect as appropriate for age ¨ Position: the person sits comfortably in a chair or on the bed or examination table, with arms relaxed at sides and head turned to examiner ¨ Body Build/ Contour: proportions are:  Arm span (fingertip to fingertip) equals height  Body length from crown to pubis is roughly equal to length from pubis to sole ¨ Physical Deformities: note any congenital or acquired defects 3. Mobility ¨ Gait: a person’s manner of walking ¨ Range of Motion 4. Behavior ¨ Facial Expression: maintains eye contact and expressions are appropriate ¨ Mood/Affect: person is cooperative with examiner and interacts pleasantly ¨ Speech: articulation is clear and understandable ¨ Dress: clothing is appropriate to the climate, looks clean and fits the body ¨ Personal Hygiene: person appears clean and groomed appropriately for his/her age, occupation, and socioeconomic group.  Hair is groomed or brushed  Makeup is appropriate for age Measurements 1. Weight

Use standardized balance or electronic scale Instruct person to remove his/her shoes and heavy outer clothing before standing on the scale ¨ When a sequence of repeated weights is necessary, aim for approximately the same time of day and the same type of clothing worn each time. 2. Height ¨ Use a wall mounted device or the measuring pole on the balance scale ¨ Person should be shoeless, standing straight, and looking straight ahead ¨ Heels, buttocks, and shoulders should be in contact with a hard surface ¨ ¨

3. Body mass index ¨ Expresses the relationship between height and weight but does not consider other variables, such as muscle mass. ¨ Underweight: less than 18.5 ¨ Normal weight: 18.5-24.9 ¨ Overweight: 25-29.9 ¨ Obesity (class 1): 30-34.9 ¨ Obesity (class 2) 35-39.9 4. Waist circumference ¨ Excess abdominal fat is an important independent risk factor for disease, over and above the of BMI ¨ Place a measuring tape around the waist parallel to the floor at the level of the iliac crest ¨ The tape should be snug but not pinch in the skin ¨ Note the measurement at the end of a normal expiration ¨ A WC of 35 inches or more in women & 40 inches or more in men increases the risk for type 2 diabetes, dyslipidemia, hypertension, CVD » Infants & Children ¨ Weight  Use balance scale; set calibration at 0  Weigh to the nearest 10g for infants and 100g for toddlers  By age 2 or 3 years use the upright scale  Upright scale for preschoolers & school age children ¨ Length  Until age 2 measure infants body length supine with a horizontal measuring board. Hold the head in the midline  Avoid using a tape measure b/c this is inaccurate  By age 2 or 3 measure the child’s height by standing them against the pole on the platform scale or against a flat ruler taped on the wall.  Hold a flat book or flat board on the child’s head at a right angle to the wall ¨ Head circumference  Measure the infants head circumference at birth and at each well child visit up to age 2 and then annually up to age 6  Circle the tape around the head at the prominent frontal and occipital bones; the widest span is correct  A newborns head measures about 32-38 cm (average about 34cm) and is about 2cm larger than the chest circumference.  Chest grows at a faster rate than the cranium; at some time between 6 months and 2years both measurements are about the same.  At age 2 the chest circumference is large than the head circumference

The aging adult ¨ Weight  Body weight decreases during the 70s and 80s o More evident in in males, perhaps b/c of greater muscle shrinkage ¨ Height  By their 70s and 80s many people are shorter than they were in their 60s  Results from thinning of the vertebral discs and shortening of the individual vertebrae as postural changes of kyphosis and slight flexion in the knees and hips  Kyphosis is an exaggerated posterior curvature of the thoracic spine (humpback) Vital signs » Temperature ¨ Normal oral temperature in a resting person is 98.6F (37c)  Range: 96.4-99.1 (35.8-37.3) ¨ Oral: measured with electronic thermometer  Use the blue end probe  Determine when last food or fluids were taken  Wait 15 –30 minutes  Remove the unit from the charger base Remove the temp probe  Attach a probe cover  Place the probe at tongue base  Listen for the beep and note the readout  Discard the probe cover  Return the unit to its charging base  Require patient cooperation  Not recommended for patients with seizure history  Leave in place for 3-4min if afebrile  Leave 8min if febrile ¨ Rectal: measured with electronic thermometer  Use only if other routes are not practical o For pts that are comatose, confused, in shock, or unable to close mouth  Make sure it is a rectal probe  Cover with disposable, sterile sheath  Lubricate the thermometer  Wear gloves  Insert 1 inch (2-3cm) into rectum directed toward the umbilicus  Result appears in display window  Remove probe  Discard cover ¨ Axillary  Follow procedure for oral except Place probe in axilla  Place patient’s arm across chest  Hold the probe in place until beep  Note temperature reading  Remove probe  Discard probe cover  Return unit to charging base ¨ Tympanic: probe inserted into ear »

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 Least invasive and provide rapid temp readings Temporal  Least invasive and provide rapid temp readings ¨ Terms for fever: ¨ Pyrexia: raised body temperature ¨ Hyperthermia: When the body loses heat faster than it can produce heat, causing a dangerously low body temperature. ¨ being febrile: having or showing symptoms of fever ¨ No fever = afebrile Pulse ¨ Determine appropriate site to obtain pulse ¨ Document - rate, rhythm, strength and elasticity ¨ HINT - Apical pulse for patients with irregular patterns or taking heart meds, as well as children younger than 2 years old. ¨ Normal adult heart rate  60 to 100 beats per minute (BPM) ¨ Rates are slightly higher in women and more rapid in infants and children ¨ Children HR range form 70-160 depending on the age group ¨ Assessment Alert  Tachycardia is HR >100  Bradycardia is HR 6 months o Cancer pain: may arise from a tumor compressing or infiltrating nearby body parts Characteristics of pain o Timing (onset, duration, and pattern) o Location o Severity Tools to help us assess pain o Visual analog scale o Wong-baker faces scale o Numeric rating scale o FLACC  F- Face  L- Legs  A- Activity  C- Cry  C- Consolability Infants cannot rate pain verbally, but they show it through behavioral and physiological clues (FLACC) Children 2 years of age can report pain and point to location. Rating scales are introduced at 4-5 years of age. The faces pain scale 0-10 how much do you hurt? Aging adults can use alternative to pain scale called the descriptor scale No pain, mild pain, moderate pain, severe pain...