037/038 Clinical observations and pain assessment

clinical observations AKA obs/vitals

• T - temperature

• P/HR - pulse or heart rate

• R or RR- respirations or respiratory rate

• BP - blood pressure

• O2 sats/SpO2 – oxygen saturations

other common assessments - clinical observations

• neurological and neurovascular observations

• breath sounds

• bowel sounds

• peak flow

• blood glucose

• height and weight

• limb and girth measurements

when are vital signs taken

• on admission to establish a reliable baseline

• routine times (QID, TDS or BD - then reviewed)

• onset of adverse event/unwell

• pre and post surgery/procedure - RPAO

• pre- and post-certain medications

• before discharge

• when you’re worried or not sure

• if in doubt, do a set of obs

observations - in general

Before:

• explain to client

• position and privacy

• equipment - dedicated to this client

• wash hands - gloves needed

• has client just exercised? had a hot shower? had a hot or cold meal/drink? pain levels, psychological state

After:

• document and compare to client’s previous readings

• wash hands

• equipment  - cleaning & storage

what controls body temp

• Hypothalamus receives info about temp of the blood and also from thermo-receptors in the skin and some internal organs

• Body temp is the balance between the heat produced and the heat lost from the body.

• Heat is produced  by cellular metabolic activity and muscle contraction and lost by radiation and evaporation

• The body keeps temperature within a narrow, safe range despite large variations in temperatures outside the body.

• normal adult temp: 35.8-37.2°C

regulatory mechanisms when the body is too hot

• vasodilation - blood vessels in the skin dilate to carry excess heat to the skin's surface

• sweating - as the sweat evaporates, it helps cool the body

We assist the process by being less active, wearing less and taking cool drinks

regulatory mechanisms when the body is too cold

• vasoconstriction - blood vessels constrict and blood flow to the skin is reduced, which conserves body heat

• shivering - involuntary, rapid contraction of muscles to generate more heat.

We assist ourselves by wearing more clothes, hot food, heating and exercise.

what increases temp

• Dehydration

• Infection – hypothalamus resets internal thermostat; we feel cold and shiver even if our temperature is over 38°C. Fevers have a cold, hot and sweat stage.

• Medications – metabolic reaction.

• Severe trauma or injury – follows head injury, CVA, or inflammation.

• Medical conditions – tumours,  arthritis,  gastritis, hepatitis.

common terms for increased temp

• Pyrexia: Temperature  above normal range

• Hyperpyrexia: Excessive and unusual elevation of body temperature greater than or equal to 41.1° C

• Febrile: Fever

• Afebrile: Normal body temperature

• Hyperthermia: Body produces more heat than it can dissipate to cool down (40°C or above). AKA heatstroke/sunstroke

what decreases temp

• Environmental temperature/exposure

• Alcohol or drug use

• Metabolic disorders such as diabetes or hypothyroidism.

• Shock

Hypothermia: core temperature of less than 35°C

• Aged clients have less subcutaneous fat; more sensitive to cold environments

assessing body temp

2 most common:

1. scanning thermometers

2. ear/tympanic thermometers

older methods - not used routinely:

• auxiliary

• oral

• groin

• rectal

• skin/chemical (liquid crystal - forehead)

DON’T use: glass thermometers - have mercury inside

forehead scanning thermometer

check manufacturing instructions – some models keep still whilst recording, others have a set movement

assessing tympanic thermometer

Tympanic membrane has abundant arterial supply from carotid artery

• Always attach new disposable cover to probe

• Infants younger than 12M: Pull the earlobe down and back

• Children older than 12M & adults: Pull the earlobe up and back.

• Centre the probe tip in the ear and push gently inward toward the eardrum. Take care not to insert too far.

oral route

1. Wait 30 mins hot or cold fluids or after smoking

2. Clean the thermometer with alcohol wipe

3. Place under the tongue, to one side, and close the lips tightly around it

4. Leave in place the required amount of time.

• DON’T use for young children or clients who are unconscious, uncooperative or have a history of fitting.

• Must be able to breathe through the nose

rectal route

• Very accurate

• May be used for small infants and when an accurate measurement is essential

• Not used for clients who have rectal surgery, diarrhoea, diseases of the rectum, or haemorrhoids

axilla route

• Used to be the preferred site in newborns, infants, children

• For those with oral inflammation, cannot breathe through nose, irrational clients

• Least accurate way to measure body temperature.

common site of pulse

• temporal, carotid, brachial, radial, femoral, popliteal, posterior tibialias, dorsalis pedal

• measured in BPM

• DON’T use thumb b/c it has its own pulse

normal pulse range

• healthy adult resting: 60-100 bpm

• sleep: as low as 40 bpm

• exercise: as high as 200-220 bpm

• infants: 12-140 bpm

• children: 90-120 bpm

• older adults: ~elevated pulse to compensate ↓ cardiac output (CO)

factors that can affect pulse rate

• medication

• baseline data, e.g. fit person may have HR of below 60bpm

• if client has been physically active, wait 15 minutes

• pain

assessing pulse - 3 components

1. Rate

• No. of beats per min.

• Tachycardia, Bradycardia

2. Rhythm

• Pattern and intervals between beats

• Arrhythmia (dysrhythmia) – irregular rhythm. 

• May be random irregular beats, or a predictable pattern of irregular beats

3. Volume

• Pulse strength – the force of blood with each beat

• May be full or bounding pulse

• Weak, feeble or thready

pulse patterns

respirations

• breaths per minute

• normal adult inspiration: 1-1.5 secs

• normal adult expiration: 2-3 secs

• asses when relaxed

• exercise ↑ rate & depth

• ~assess after activity to identify tolerance

• be aware of normal breathing pattern

respiratory rates - normal ranges

• infants: 28-40 bpm

• children: 20-28 bpm

• adults: 12-20 bpm

assessing respirations

1. Rhythm

• Refers to the regularity of breathing

• Respirations should be evenly spaced

2. Quality

• Aspects that are different from normal, effortless breathing

• Laboured breathing – breathing with effort

3. Depth

• Establish by watching the chest movement

• Described as normal, deep or shallow

• During normal breathing an adult takes in about 500ml of air. This volume is known as the “tidal volume”

• Body position affects the amount inhaled

facors affect respirations

Increase the rate:

–exercise

–stress

–increased environmental temperature

–low oxygen concentration (increased altitudes)

Decrease the rate:

–decreased environmental temperature

–medications e.g. narcotics (morphine)

–increased intracranial pressure (head injuries)

–health states

–age, elderly residents

assessing respirations

Sound:

• Normal breathing is silent

• Some sounds are audible e.g. wheeze

• Many sounds occur as a result of the presence of fluid in the lungs

common breath sounds

• Wheezing

• Rhonchi – low-pitched wheezes

• Stridor

• Crackles – fine and coarse (aka Rales)

• Pleural friction rub

wheezing

Caused by narrowing of the airways, associated with

• Asthma

• Bronchitis

• Pneumonia

• COPD

• Smoking

• Heart failure

• inhaling a foreign object into the lungs

• allergic reaction

Rhonchi

Occur in the bronchi

• Snoring or moaning sound

• Continuous, snoring, gurgling or rattle–like quality

• Occur as air moves through tracheal-bronchial passages coated with mucous or respiratory secretions

• Often heard in pneumonia, chronic bronchitis or cystic fibrosis

• Usually clear after coughing

Stridor

Air is moving roughly over a partially obstructed upper airway; Caused by something blocking the larynx

•choking on an object

•infection

•throat swelling

•laryngospasm

Crackles – fine

• High-pitched, brief, discontinuous popping lung sounds

• Sounds like wood burning

• Usually start at the base of the lungs, where there is fluid in the lungs

• As fluid fills the lungs more, it can be heard closer to the top of the lungs

Crackles – coarse

• Coarse, rattling, crackling sounds – louder, longer and lower in pitch than fine crackles

• Described as a bubbling sound, as when pouring water out of a bottle or like ripping open Velcro

• Often heard just in certain spots in the lungs, possibly only one side or in different spots on both sides

• Usually caused by mucous/fluid in the bronchi

Respiratory distress 

Physically laboured ventilation or respiratory efforts

Dyspnoea

shortness of breath/difficulty breathing

Tachypnoea

greater than normal respiratory rate

Work of breathing (WOB)

muscle use, visible effort to breathe

Hyperventilation  

Deep, rapid respirations

Apnoea

Cessation of breathing for a period

Cheynes - Stoke

Hyperventilation followed by apnea

Oxygen saturation/pulse oximetry

O₂ saturation: a measure of how much O₂ the blood is carrying as a % of the maximum it could carry.

• 1 haemoglobin carries max. 4 molecules of O₂,

• E.g. 3 molecules of O₂ = 75% of the maximum amount of oxygen it could carry

measuring oxygen saturation

Estimate of oxygen saturation = Pulse oximeter

• Clip shines a light through one side of the finger; a detector measures the light that comes through the other side.

• desired pulse oximetry reading: 98 and 100%

• 95-98% = ask them to slow down breathing

oximeter probe sites

• fingers

• ear lobe

• bridge of nose

• toes/feet

peak flow meters

measures forced expiratory reserve volume (V)

1. Client inhales fully and then exhales as quickly and completely as they can

2. Typically, do 3 readings before and after ventolin to gauge the effectiveness of the bronchodilating medication

BP

Measures the pressure exerted by the blood as it flows through the arteries

• measured in millimetres of mercury (mmHg) and recorded as a fraction

• avg. BP = 120/80mmHg; however, it is important to know what is normal for a client as they go from rest to physical exertion

Systolic and diastolic pressure

Systolic: amount of pressure exerted against the arterial wall as the left ventricle contracts

• Systolic pressure range: 100-140 mmHg

Diastolic: amount of pressure exerted against the arterial wall as the left ventricle relaxes

• Diastolic pressure: 60-90 mmHg

Normal range: 100-140/60-90 mmHg

factors affecting BP

Pumping action of the heart:

• Weak heart pump = less blood is pumped into the arteries, and BP ↓

• Strong heart pump and the V of blood pumped into the circulation increases = BP ↑

Peripheral vascular resistance:

• Smaller space within a vessel = greater resistance

• Increased vasoconstriction = BP ↑

• Decreased vasoconstriction = BP ↓

Blood volume (V):

• Dehydration & haemorrhage will ↓ blood V and BP because of decreased fluid in the arteries

• When V ↑ = BP ↑ because of greater fluid volume in the circulatory system

Blood viscosity:

• BP higher when blood is highly “viscous” (thicker)

BP may change due to:

(These factors often cause falls & faints)

• ↓ blood V – hypovolaemia, always think of dehydration & haemorrhage (also fluid intake, urine output)

> Is the client dehydrated?

> Are they bleeding?

• Changes in position/posture – postural hypotension

• Changes in temperature – vasodilation/vasoconstriction

• The effects of medication – new or increased doses

• stress/anxiety

• pain

• nutritional factors

• drugs

• disease

• older adults tend to have elevated systolic blood pressure

• Hypertension: blood pumps w/ more force than normal = approx. 150/100mmHg

• Hypotension: more likely seen by specific symptoms, but approx. 100/50mmHg

equipment to measure BP

manual BP assessment - preparation

1. Cuff size is appropriate

2. Patient is sitting or lying comfortably, choose appropriate arm to perform BP – if required, support arm with pillow

3. Access patient’s upper arm – remove clothing or roll up sleeve

manual BP - step 1: determine radial systolic BP

1. Palpate the brachial artery

2. Place cuff 2.5cm above antecubital fossa (bend in elbow) to allow room for stethoscope diaphragm in fossa

3. Whilst palpating radial pulse, slowly inflate cuffs until pulse cannot be felt, inflate a further 5mmHg

4. Slowly deflate cuff & note where pulse returns

5. Leave cuff on arm for step 2

manual BP - step 2: auscultate BP

1. Place stethoscope diaphragm over brachial artery

2. Inflate cuff 200-30mmHg above palpated radial systolic read

3. Whilst deflating cuff slowly, note reading on sphygmo gauge when pulse beat is 1st heard

4. Continue to slowly deflate cuff & note reading when pulse sound disappears

5. Allow remaining air in cuff to escape

6. Remove cuff, adjust patient’s clothing & position if required

7. Document, hand hygiene & follow-up action if required

BP is usually measured on the arm using the brachial artery and stethoscope except if:

• Client has removed axillary nodes on that side – common with mastectomies

• IV infusion on that arm

• Arterio-venous fistula (renal dialysis)

limb and girth measurements

• girths are circumference measures using tape measure

• determines body size and composition, & monitor changes

assessing bowel sounds

1. Empty bladder

2. Lie supine with pillow under head

3. Expose abdomen (maintain privacy) from above xiphoid process to the symphysis pubis

4. Picture abdomen in 4 quadrants

5. Stand on right side, look at abdomen from side and above, & xiphoid process to symphysis pubis to determine if it’s flat, scaphoid, rounded or protuberant

6. If protuberant, ask if it’s normal for them

7. Place diaphragm over RLQ & listen for bowel sounds

8. If you don’t hear any, continue listening for 5 mins in RLQ

9. Then, listen to RUQ → LUQ → LLQ

10. Describe sounds as absent, normoactive, hypoactive or hyperactive

• Absent ~indicate ileus or peritonitis

• Hyperactive ~early intestinal obstruction or gastrointestinal hypermotility

definition of pain + types

an unpleasant sensation occurring in various degrees of severity as a consequence of injury, disease or emotional disorder

• types: acute or chronic

physiological effects of pain

• ↑ catabolic demands → poor wound healing, weakness & muscle breakdown

• ↓ limb movement → ↑ risk of DVT/PE

• respiratory effects: shallow breathing, tachypnea & cough suppression → ↑ risk of pneumonia & atelectasis

• ↑ sodium & water retention (renal)

• ↓ gastrointestinal mobility

• tachycardia & elevated BP

• negative emotions: anxiety, depression

• sleep deprivation

what does pain mean to clients?

• poor prognosis or impending death – esp. when pain worsens

• ↓ autonomy (independence/freedom)

• impaired physical or social functions

• ↓ enjoyment & quality of life

• challenges to dignity

• threat of ↑ physical suffering

neuropathic pain

pain transmitted over damaged nerves

• described as burning, electric, searing, tingling & migrating

• causes: amputation, shingles, diabetic neuropathy, fibromyalgia & cancers that affect spinal cord, etc.

principles of pain assessment

• assess & reassess

• use methods appropriate to cognitive status & context

• assess intensity, relief, mood & side effects

• use verbal report when possible

• document in a visible place

• accountability

• include the family

client pain history

• site/s of pain

• severity of pain

• date of onset

• duration

• what aggravates or relieves pain

• impact on sleep, mood & activity

• effectiveness of previous meds

0-10 pain assessment method

PQRST method of pain assessment

P = Provocation/Palliation

• Cause? Trigger? Stress? Position? Certain activities?

• Relieves? Meds, massage, heat/cold, position, active, rest?

• Aggravates? Movement, bending, lying, walking, standing?

Q = Quality/Quantity

• Describe pain: sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching.

R = Region/Radiation

• Location? Radiate? Where? Travels/moves around? Start elsewhere and now localised to one spot?

S = Severity Scale

• 0-10? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

T = Timing

• When start? How long last? How often does it occur? Sudden or gradual? When occur? Awakened by it? Lead to anything else? Accompanied by other symptoms? Occur before, during or after meals?

Pharmacological management of pain

Mild to moderate pain:

•NSAID’s (nonsteroidal anti-inflammatory drugs) eg

paracetamol (Panadol), ibuprofen (Nurofen)

•Cox 2 inhibitors are a form of (NSAID) that directly targets COX-2, (cyclooxygenase-2) an enzyme responsible for inflammation and pain eg Celecoxib (Celebrex)

Moderate to severe pain:

•Morphine sulphate

•Oxycodone

•Codeine

•Oxycontin

•Methadone

•Fentanyl

•Hydromorphine

•

Principles of opioid analgesic use in acute and cancer pain

•Individualise route, dosage, and schedule

•Administer analgesics regularly (not PRN) if pain is present most of day

•Become familiar with dose / time course of several strong opioids

•Give infants / children adequate opioid dose

•Follow clients closely, particularly when beginning or changing analgesic regimens

Important principles

•Round the clock dosing for predictable pain

•start Low, go Slow

•the client is the ultimate authority on their pain – do not second guess them

Barriers to opioid use

•Fears about addiction

•Underestimating pain

•Normalising pain

Non pharmacologic management of pain

Do not teach these when the client is in an acute pain episode

Use in conjunction with, not instead of pharmacologic methods

•Exercise

•Heat/cold application – use with caution

•Lotions/massage therapy – use with caution

•Positioning – including pillows and pressure relieving devices/aids

•Aqua-therapy, including showers/baths

•Transcutaneous electrical nerve stimulation (TENS)

•Acupuncture/acupressure