Chapter 9,10: General Survey, Vital Signs, Pain
I. Acute Assessment
1. Indicators of acute situations:
● Extreme anxiety, acute distress, pallor (pale appearance)
● Cyanosis (blue discoloration), change in mental status
2. Interventions begin while continuing assessment
3. Normal BP: 120/80
4. Normal Oral Temp: (resting person) 98.6 (range between 96.4-99.1)
● Rectal temp is one degree higher
● Axillary temp is one degree lower
5. Normal Resting HR:60-100bpm
6. Adult Respiratory Rate: 10-20 breaths/min
7. Normal pulse oximetry: SpO2 from 92-100%
● SpO2 of 85-89% acceptable for patients with chronic conditions like
emphysema
8. Rapid response team may be called for:
● Acute change in mental status
● Stridor ( a harsh vibrating noise when breathing caused by windpipe or
larynx obstruction)
● Respirations of less than 10 or >32 breaths per min
● Increased effort to breathe
● Oxygen saturation <92%
● Pulse <55 bpm or >120 bpm
● Systolic BP <100 or >170
● Temp is <35C or >39.5C
● New onset of chest pain
● Agitation or restlessness
II. General Survey
1. First component of assessment
2. Forms global impression of person or broad idea
3. Difference btwn light and deep palpation (ch.8)
4. ASSESS: overall appearance, hygiene and dresss, skin color, body structure and
development, behavior, facial expression, level of consciousness, speech (slow,
normal monotone?), mobility
5. ANTHROPOMETRIC MEASUREMENTS: height, weight, BMI
6. VITAL SIGNS: reflect health status, cardiopulmonary fxn, overall body fxn, need
to assess patient medications first, frequency, baseline
7. TEMPERATURE: normal range depends on route used
8. PULSE: arterial pulse points
● More than 100 = tachycardia
● Less than 50 = bradycardia
I. Acute Assessment
1. Indicators of acute situations:
● Extreme anxiety, acute distress, pallor (pale appearance)
● Cyanosis (blue discoloration), change in mental status
2. Interventions begin while continuing assessment
3. Normal BP: 120/80
4. Normal Oral Temp: (resting person) 98.6 (range between 96.4-99.1)
● Rectal temp is one degree higher
● Axillary temp is one degree lower
5. Normal Resting HR:60-100bpm
6. Adult Respiratory Rate: 10-20 breaths/min
7. Normal pulse oximetry: SpO2 from 92-100%
● SpO2 of 85-89% acceptable for patients with chronic conditions like
emphysema
8. Rapid response team may be called for:
● Acute change in mental status
● Stridor ( a harsh vibrating noise when breathing caused by windpipe or
larynx obstruction)
● Respirations of less than 10 or >32 breaths per min
● Increased effort to breathe
● Oxygen saturation <92%
● Pulse <55 bpm or >120 bpm
● Systolic BP <100 or >170
● Temp is <35C or >39.5C
● New onset of chest pain
● Agitation or restlessness
II. General Survey
1. First component of assessment
2. Forms global impression of person or broad idea
3. Difference btwn light and deep palpation (ch.8)
4. ASSESS: overall appearance, hygiene and dresss, skin color, body structure and
development, behavior, facial expression, level of consciousness, speech (slow,
normal monotone?), mobility
5. ANTHROPOMETRIC MEASUREMENTS: height, weight, BMI
6. VITAL SIGNS: reflect health status, cardiopulmonary fxn, overall body fxn, need
to assess patient medications first, frequency, baseline
7. TEMPERATURE: normal range depends on route used
8. PULSE: arterial pulse points
● More than 100 = tachycardia
● Less than 50 = bradycardia
