Chapter 1

• General Survey


  Includes the following:

  1. Physical development and body build

  2. Gender and sexual development

  3. Apparent Age as compared to reported age

  4. Skin condition and color

  5. Dress and Hygiene

  6. Posture and gait

  7. Level of consciousness

  8. Behaviors, body movements, and affect

  9. Facial Expression

  10. Speech

  11. Vital signs
• Vital Signs


  The body's indicators of health
• Examples of Vital Signs

  • Temperature
  • Pulse
  • Blood pressure
  • Respirations
  • Pain
• "The Joint commission designated PAIN as the 5th vital sign because of its chronic and under treatment."
• Pain


  An early predictor of impending disability
• Temperature


  Core body temperature is 36.5 - 37.7'C. Temperature can be taken at various anatomic sites, none of which are completely accurate but an approximate reflection of the core of the body.
• Factors that may affect normal variations in the core of the body temperature include strenuous exercise, stress, and ovulation.
• Hypothermia


  Less than 36'C or 97'F, may be seen in prolonged exposure to the cold, hypoglycemia, hypothyroidism or starvation
• Hyperthermia


  More than 38'C or 96'F, may be seen in viral or bacterial infection, malignancies, trauma and various blood, endocrine and immune disorders
• Pulse


  A shock wave produced when the heart contracts and forcefully pumps blood out of the ventricles into the aorta. The radial pulse gives a good overall picture of the client's health status.
• Characteristics of the radial pulse

  • Absent
  • Weak, diminishes (easy to obliterate)
  • Normal (obliterate with moderate pressure)
  • Bounding (unable to obliterate or requires firm pressure)
• Respirations


  The respiratory rate and character are additional clues to the client's overall health status. Notable characteristics are rate, rhythm, and depth.
• Blood Pressure


  Reflects the pressure exerted on the walls of the arteries, varying with the cardiac cycle, reaching a high point with systole and low point with diastole. Expressed as the ratio of the systolic over the diastolic pressure.
• Factors that affect Blood Pressure

  • Cardiac output
  • Peripheral Vascular Resistance
  • Circulating Blood volume
  • Blood viscosity (thickness)
  • Elasticity of blood vessels
• A client's blood pressure will normally vary throughout the day due to factors like time of day, caffeine/nicotine intake, exercise, emotions, pain, and temperature.
• Pain


  "Pain is whatever the person says it is." (McCaffery and Pasero, 1999)
• The Joint Commission standards for Pain Management require health care providers and organizations to improve pain assessment and management for all patients.
• Joint Commission Standards for Pain Management

  • Recognize that patients have a right to appropriate pain assessment and management
  • Screen initially and assess periodically for pain (nature and intensity)
  • Record pain assessment results and follow-up with reassessments
  • Assess staff for level of knowledge and educate in pain assessment and management as needed
  • Establish organizational policies and procedures that support appropriate ordering or prescribing of effective pain medications
  • Educate patients and their families about the importance of effective pain management
  • Address patient needs for symptom management in the discharge planning process
  • Collect data to monitor the appropriateness and effectiveness of pain management
• Physiologic Responses to Pain


  Pain elicits a stress response in the human body that triggers the sympathetic nervous system, resulting in physiologic responses like anxiety, fear, increased heart rate, decreased gastric and intestinal motility, and more.
• Physiologic Responses to Pain

  • Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide
  • Focus on pain, reports of pain, cries and moans, frowns and facial grimaces
  • Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilated pupils
  • Increased heart rate; peripheral, systemic, and coronary vascular resistance; increased blood pressure
  • Increased respiratory rate and sputum retention, resulting in infection and atelectasis
  • Decreased gastric and intestinal motility
  • Decreased urinary output, resulting in urinary retention, fluid overload, depression of all immune responses
  • Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons; decreased insulin, testosterone
  • Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism
  • Muscle spasm, resulting in impaired muscle function and immobility, perspiration
• Classifications of Pain


  • Acute pain
  • Chronic nonmalignant pain
  • Cancer pain
• Pain Location Classifications


  • Cutaneous pain (skin or subcutaneous tissue)
  • Visceral pain (abdominal cavity, thorax, cranium)
  • Deep somatic pain (ligaments, tendons, bones, blood vessels, nerves)
• Radiating Pain


  Perceived both at the source and extending to other tissues
• Referred Pain


  Perceived in body areas away from the pain source
• Phantom Pain


  Perceived in nerves left by a missing, amputated, or paralyzed body part
• Neuropathic Pain


  Causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels, but exact mechanisms are unclear
• Intractable Pain


  Defined by its high resistance to pain relief
• Selected Nursing Diagnoses


  • Readiness for enhanced spiritual well-being related to coping with prolonged physical pain
  • Readiness for enhanced comfort
  • Risk for activity intolerance related to chronic pain and immobility
  • Risk for constipation related to nonsteroidal anti-inflammatory agents or opiates intake or poor eating habits
  • Risk for spiritual distress related to anxiety, pain, life change, and chronic illness
  • Risk for powerlessness related to chronic pain, health care environment, pain treatment–related regimen
  • Acute pain related to injury agents (biologic, chemical, physical, or psychological)
  • Chronic pain related to chronic inflammatory process of rheumatoid arthritis
  • Ineffective breathing pattern related to abdominal pain and anxiety
  • Disturbed energy field related to pain and anxiety
  • Fatigue related to stress of handling chronic pain
  • Impaired physical mobility related to chronic pain
  • Bathing/hygiene self-care deficit related to severe pain (specify)
• Mental Health


  An essential part of one's total health and more than just the absence of mental disabilities and disorders. A state of well-being in which the individual realizes his or her own abilities, and can cope with the normal stresses of life, can work productively and is able to make a contribution to his/her community.
• Mental Disorders


  Any condition that characterized by cognitive and emotional disturbances, abnormal behaviors, impaired functioning, or any combination of these. Multiple components can contribute to these disorders such as environmental conditions, psychological, genetic, chemical, social, and other factors.
• Mental disorders may affect other body systems when prompt assessment and intervention are delayed. For example, clients with depression may have decreased or loss of appetite and over time develop nutritional deficiencies that affect the gastrointestinal system as well as other body systems.
• Factors Affecting Mental Health

  • Economic and social factors, such as rapid changes, stressful work conditions and isolation
  • Unhealthy lifestyle choices such as sedentary lifestyle or substance abuse
  • Exposure to violence such as being a victim of child abuse, spouse or significant other abuse, active military, veterans and refugees and immigrants from violent environments
  • Personality factors such as poor decision-making skills, low self-concept, and poor self-control and spiritual factors
  • Cultural factors – culture plays a role in perception in illness, especially in illnesses associated with mood and mental status, called culture-bound syndromes
  • Change or impairments in the structure and functions of the neurologic systems
  • Psychological developmental level and issues
• Growth


  Addition of new skill and component
• Development


  Refinement, expansion or improvement of existing skills or components
• Psychosocial


  The intrapersonal and interpersonal responses of a person to external events
• Piaget's Cognitive Theory of Development


  A description and explanation of the growth and development of intellectual structures, focusing on how a person learns, not what the person learns
• Kohlberg's Theory of Moral Development

  A comprehensive theory of moral development, most concerned with the reasoning of a person used to make a decision, as opposed to the action that resulted after the decision was made. Kohlberg viewed justice (or fairness) as the goal of moral judgement and proposed 3 levels of moral development encompassing 6 stages.
• Kohlberg assumed that a person must enter moral stage hierarchy in an ordered and irreversible sequence, and may never attain a higher stage of moral development.
• Kohlberg did not theorize that infants and young toddlers were capable of moral reasoning, viewing them as naïve and egocentric.
• In preparing the patient, as with the collection of subjective data in the nursing history, maintain a caring, helping, trusting relationship while assessing their developmental level. The assessment of the client's developmental level is a lengthy process that occurs overtime as the nurse develops a working relationship with the client.