Chap 2,4,6: Pain Assessment & Documentation

What is the primary purpose of the nurse patient relationship

To support patients heath, healing, and well being, while fostering trust to share information honestly

What is therapeutic communication

Starts with caring, empathy, self concept

• Important and understanding, enabling effective exchange of information and feelings that promote patient health.

What is nonverbal communication

Physical appearance, posture, expressions, eye contact

• ex. asking permission to touch people don’t assume,

What is active listening

• ability to focus on patients and their perspectives

• talking about difficult feelings and responding thoughtfully

What is cultural competent communication

Recognizes and respecting cultural differences in interactions, valuing diverse perspectives, and promoting inclusive communication practices.

What are the phases of the interview process

• preinteraction phase

• beginning phase

• working phase

• Closing phase

What is the preinteraction phase

preparing for patient interview from existing medical records

What is the beginning phase

Introduction and stating purpose for interview

Working phase

Direct specific questions and open ended questions to get data (subjective and objective)

Closing phase

Summarizing key points and explain key points

Types of health history

• emergency

• focused

• comprehensive

Emergency health history

In urgent situations, Nurses collect the most important information

Focused health history

Directing towards a particular or current situation (more specific on body systems)

Comprehensive heath history

Takes place at annual physical, looking at many different things

What are the components of health history

• demographic data

• reason for seeking care

• History of present illness (OLDCARTS)

• allergies

• family history

what is acute pain

Short duration and has an identifiable cause

Chronic pain

Last longer than normal healing period (3-6 months)

Visceral pain

Arises from abdominal organs

• described as cramping or aching

Somatic pain

Comes from muscles, bones, or joints

• Described as sharped localized, or well defined

Cutaneous pain

From the skin in subcutaneous tissues

• Sharp or burning sensation

Referred pain

Begins in one location but is felt in another location

• Cardiac pain, indigestion, neck discomfort

Phantom pain

Neuropathic pain felt in part of body that is no longer there

Neuropathic pain

Damage to the nerves or CNS

• neuropathy

Nociplastic pain

Pain that arrives from alter perception but there is no clear evidence of tissue damage

Is the patient medical record a legal document

YES!!

• Can be used in court if there is ever an error or dispute regarding patient care.

What is the patient medical record used for

Way to communicate, way to ensure quality care is being delivered, education, research, and financial reimbursement purposes

What are never events

Events that Medicare and Medicaid have stopped reimbursement for because they are preventable and should’ve never happened

What are priority urgent assessments

Warrant immediate attention and interventions

What is the nurses response to an urgent situation

• Recognize problem

• Intervene

• Communicate

• Document

• Reassure the patient

What are “SOAP” notes

S: subjective assessment

O: Objective assessment

A: Analysis

P: Plan

In what phase of the interview are open ended questions asked

Working phase

What is mild pain rated between

1-3

What is moderate pain rated between

4-6

What is severe pain rated between

7-10

A nurse is assessing the vital signs of a client who is moaning with pain. What would be the expected findings.

Increase pulse and bp

What type of pain would the instructor explain originates from a specific site, yet the client feels the pain at another site.

referred pain