● General survey

○ physical appearance
■ do they appear their stated age?
■ sex, and sexual development (too early, too soon?)
■ Level of consciousness (LOC)
■ skin color: appropriate for their race, even colored
● erythema: red color
● pallor: white color
● jaundice: yellow color
● cyanosis: blue color
■ facial features: correct size, symmetrical, s/s (signs or symptoms) of
distress
○ Body structure
■ stature: is height appropriate for age and race?
■ nutrition: too much, too little
■ symmetry: difference in size, deformity on one side, etc
■ posture: comfortable, not shifting
■ position: guarding, bracing
■ body build, contour: proportions are correct
○ Mobility
■ gait: even, heal to toe, arms swing
■ range of motion
○ Behavior
■ facial expression: (incl eye contact) may vary by ethnicity
■ mood and affect: how do they react?
■ speech: clear, articulated, fluent, even pace, correct word choice
■ dress: appropriate to climate, clean and fitting well
■ personal hygiene: is their dress culturally appropriate, any recent changes
● Measurement
○ Weight
■ make sure they don’t touch anything
■ BMI charts are important, required in Obamacare
● Weight (kg) / Height (m)
○ Height
■ most PTs don’t know their height
■ know how to convert from cm to in
● Vital signs
○ written in order: T-P-R-BP == 98.6-80-20-120/80
○ temperature
■ can be influenced by:
● diurnal cycle
● menstrual cycle
● exercise
● age
 ■ routes and methods of taking temp
● oral
● axillary (armpit)
○ newborns and toddlers
● rectal (in da butt)
● tympanic membrane thermometer
■ Always note temp and route: 98.6 - axillary
○ pulse
■ technique
● 60 seconds if first visit or irregularity is detected
■ rate
● normal 50-90
● bradycardia <50
● tachycardia >90
■ rhythm
● document as regular or irregular
■ force
● documented as 0 (non-palpable) - +3 scale
■ elasticity
○ Respirations
■ don’t let the PT know you are counting resps
■ ratio to pulse should be approx 4:1
○ Blood Pressure
■ systolic
● the big number
● max pressure during left ventricular contraction
■ diastolic
● the small number
● the steady pressure between heartbeats
■ pulse pressure
● subtract diastolic from systolic: 120/80 -> 120-80=40
■ mean arterial pressure (MAP)
● pressure forcing blood into the tissues
■ avg is 120/80
● hypertension 140/90
● hypotension 100/60
● influenced by:
○ age
○ race
○ emotion
○ sex
○ diurnal cycle
○ excercise
○ stress
 ■ physiological factors change BP
■ Karotkoff’s sounds
● I - First heard sound: systolic pressure
● IV - sound muffles, sounds like swishing
● V - sound stops: diastolic pressure
■ Orthostatic
● take BP and pulse rate with PT laying, sitting and standing
● shows that anti hypertensives are too much or there is blood loss
■ Thigh blood pressure is higher than bicep
● Pain
○ nociceptors receive pain, pass signal along
○ poor pain control over time can lead to hypersensitivity
○ nociception p160-161
■ transduction
● from the stimulation of pain
■ transmission
● neurotransmitters pass message along
● opioid receptors can block pain transmission
■ perception
● the “ouch”
■ modulation
● you are able to stop processing the pain
○ Neuropathic pain
■ abnormal processing of pain signal
■ can happen 2-3 years after injury is healed
■ difficult to assess and treat
○ Sources of pain
■ visceral
● larger organs
● direct injury, stretching or lack of blood to organ
● often includes pallor, sweating, nausea
■ Deep somatic
● joints, tendons or muscles
● injury due to pressure or trauma
■ cutaneous
● skin
■ Referred pain
● pain that manifests in an area different from the origin of the issue
■ psychogenic pain
● pain with no known physical cause
○ Types of pain
■ Acute
● short lived
● tells tissue damage
 ● less than 6 mos in length
■ chronic/persistent
● lasts > 6 mos
● level of intensity does not equal the level of damage
● does not stop when injury heals
■ THE MOST IMPORTANT AND RELIABLE MEASURE OF PAIN IS THE
PT’S REPORT
■ Questions to ask: PQRSTU
○ Objective assessment
■ joints
● size and shape
● AROM (active range of motion) / PROM (passive range of motion)
■ muscles/skin
● deformities, masses
● color/swelling
■ Abdomen
● contour/symmetry
● guarding
■ Pain behavior
● nonverbal cues - facial expressions
● acute:
○ guarding
○ grimacing
○ vocalizations
○ agitation
○ stillness
○ diaphoresis
○ change in VS
● chronic
○ bracing
○ rubbing
○ diminished activity
○ sighing
○ change in appetite
○ excercise
○ prayer
● Substance use assessment - CH6
○ alcohol use
○ illicit drug use
■ may need to list specific drugs
■ most commonly abused Rx drugs
● oxycodone
● hydrocodone
● methadone
 ■ Prevalence of alcohol use decreases as age increases (slide 6-11,12)
○ Subjective data
■ difficult if they are currently under the influence
■ alcohol use: may need to ask individual alcohol types (beer, wine, etc)
■ CAGE or AUDIT
■ recommend that PT stay at moderate drinking level
■ there is NO safe level of alcohol during pregnancy
■ Tolerance applies to all substances (slide 6-21).
■ withdrawal: a physical response to reduction of substance
■ use of alcohol or MJ can indicate use of other substances
■ drug levels in urine tests are recorded as positive or negative
● Domestic Violence - CH7
○ violence can be physical, sexual, psychological or emotional
○ RNs are mandated reporters: you are legally required to report if you SUSPECT
abuse
○ Elder abuse and neglect
■ neglect - failure to provide care
■ abuse - violence, psychological, etc
■ financial abuse - intentional misuse of resources
○ health effects of violence
■ injury
■ chronic health problems
● vague complaints - they are hoping for help
■ depression
■ suicide
■ PTSD
■ substance abuse
■ chronic pelvic pain
■ UTI
■ STD
■ pregnancy/abortion
○ Abuse assessment screen (AAS)
■ should be used almost every contact with PT in emergency visit
■ a yes answer on ANY question needs to go through a full follow up
○ Elder abuse screen
■ focuses more on finances and being forced to sign papers
○ History
■ prior abuse
● shows a pattern
■ history of traumatic injury
■ mental status exam
○ physical exam
■ check for signs of abuse
● contusions, incisions, hematoma, etc
 ○ documentation
■ use lots of direct quotes
■ use injury maps
■ photographic evidence
● include PT name in photo
■ danger assessment
● map abuse on a calendar
■ followup
● Skin, hair and nails ch12
○ anatomy and structure: review on your own
○ clubbing can show signs of chronic resp deficiencies
○ functions
■ protection
■ perception
■ temp regulation
■ identification
■ communication
■ wound repair
■ absorption and excretion
■ creation of vitamins
○ history
■ previous skin disease
■ change in moles, pigmentation
■ dryness or moisture
■ medications, including medicated lotions
■ change in nails
■ env/occupational hazards
■ hair loss/changes in hair texture
■ self care behaviors
○ objective data
■ equipment needed
● light
● ruler
● gloves
■ skin - assess along with full assessment
● inspect and palpate
■ moisture
● diaphoresis
● dehydration
■ skin
● edema
● turgor - elasticity of skin
○ prolonged skin tenting shows dehydration
● vascularity and bruising
■ lesions
● color and elevation
○ is the mole uniform in color
● pattern and shape
○ confluent - spots run together (eg hives or rash)
● size
● location and distribution
○ generalized or specific area
● exudate
○ color?
○ thickness?
■ hair
● color
○ uniform, changes
● texture
● distribution
○ normal for sex and level of puberty
● lesions
● parasites
■ nails
● shape and contour - profile
● color
○ capillary refill - should be <3 sec
■ teach self-exam
● A-asymmetry
● B-border
● C-color
● D-diameter
● E-elevation
■ Primary skin lesions (slide 12-27)
● wheal - happens during PPD test
■