Midterm 1

Pain Assessment

• OPQRSTUV

Pain Assessment: Onset

• When did the pain start?

Pain Assessment: Provocative or palliative

• Increase with movement or activity?

• Relieved with rest?

• Previous treatments effective?

Pain Assessment: Quality of pain

• What does your pain feel like?

• Words to describe pain?

Pain Assessment: Region of body/Radiation

• Where?

• Radiates?

Pain Assessment:Severity

• How would you rate on an intensity scale?

Pain Assessment: Timing/Treatment

• Constant, dull, or intermittent?

• Changed over time?

• Pain-free periods?

• What treatments have worked in the past?

Pain Assessment: Understanding of pain

• What patient believes is causing the pain?

Pain Assessment: Values

• What is your acceptable level of pain?

• Anything else?

Visual analogue scale 

• A tool that uses a line or scale to help rate pain intensity 

Numeric rating or descriptive scale 

• 0 - 10 (10 being the worst pain you have ever felt)

 Faces pain scale 

• Can be administered to patients 4-5 years of age (6 faces ranging from no pain to very much pain)

Nonverbal/Behavioral Pain Assessment:

• Acute pain behaviours

• Persistent (chronic) pain behaviours

• The unconscious individual

Nonverbal/Behavioral Pain Assessment: Acute pain behaviours

• At high risk of undertreatment if unable to report pain

• If nonverbal but cognitively intact, the intensity may be indicated by a numerical rating scale, written description, or pointing to the location 

Nonverbal/Behavioral Pain Assessment: Persistent (chronic) pain behaviours

• Adapt over time

  • May give little indication of pain

  • Higher risk for under detection

• Ask pt how he or she behaves when in pain

Nonverbal/Behavioral Pain Assessment: The unconscious individual

• Grimacing, wincing, moaning, rigidity, arching, restlessness, shaking, pushing to indicate pain

Before Assessment:

• Gather all supplies

  • Pt gown/drape, stethoscope, thermometer, sphygmomanometer (blood pressure cuff), pulse oximeter, penlight, otoscope, ophthalmoscope, pen/paper or computer

• Ensure room is lit well, & warm

• Scan to see what is connected to pt

• Wash hands

• Follow routine practices & additional precautions

General Approach to Assessment:

• Reduce pt anxiety by being confident, self-assured, considerate, and unhurried

• It is normal as a beginning practitioner to feel less self-assured with worry about technical skill, missing a finding, forgetting a step, dealing with a partially dressed pt

• Use a systemic approach (head-to-toe, systems, pre-printed form)

• Document findings as you go

• Engage in pt education as you go

• Consider developmental differences

  • Do vital signs

Subjective Data: health history (skin)

• Previous history of skin disease (allergies, hives, psoriasis, or eczema)

• Change in pigmentation

• Change in mole skin/colour

• Excessive dryness or moisture

• Pruritus: itching

• Excessive bleeding

• Rash or lesion

• Medications

• Hair loss

• Change in nails

• Environmental or occupational hazards 

• Self-care behaviours

Objective data: physical examination (skin)

• Equipment needed

  • Strong direct lighting 

  • Small centimetre ruler

  • Penlight

  • Gloves

• Look in skin folds, at feet, between toes (dark, warm, moist)

• Braden scale can predict pressure sore risk

Objective data: SKIN (Inspect and palpate)

• Colour

  • General pigmentation

    • Presence of freckles, moles, birthmarks

  • Widespread colour change

    • Pallor

    • Erythema

    • Cyanosis

    • Jaundice

• temp-hypothermia/hyperthermia

• Moisture- diaphoresis/dehyrdation 

Mole Assessment

• A: Asymmetry

• B: Boarder

• C: Color

• D: Diameter

• E: Evolving

ABCDE Mole Assessment: Asymmetry

• if you draw a line through the middle of the mole, the halves of a melanoma will NOT match sizes

ABCDE Mole Assessment: Boarder

• the edges of an early melanoma tend to be UNEVEN, crusty or notched

ABCDE Mole Assessment: Color

• healthy moles are uniform in colour.

• A variety of colours, especially white/blue is BAD

ABCDE Mole Assessment: Diameter

• melanomas are usually larger in diameter than a pencil eraser, although they can be smaller

ABCDE Mole Assessment: Evolving

• when a mole changes in size, shape or colour, or begins to bleed or scab, this points to danger

Objective Data: SKIN

• inspect/palpate

  • Texture

  • Thickness

  • Edema

  • Turgor

  • vascularity/bruising

• Lesions

  • Colour

  • Elevation

  • Pattern/shape

  • Size 

  • location/distribution on body

  • Exudate 

Infants: Skin

• Stork Bite: red mark

• Mongolian spot: black mark

• Cafe-au-lait spot: light brown mark

• Jaundice: yellow

• Milia: bumps on baby’s face like acne

Objective Data: Inspect & Palpate (hair)

• Colour

• Texture

• Distribution

• Lesions

Objective Data: Inspect & Palpate (nails)

• Shape & contour

  • Profile sign

• Consistency

• Colour

  • Capillary refill (holding on nail bed)

• Inspect fingernail plate shape, curvature, and angle

Subjective Data: Health History (ears)

• Earaches (otalgia)

• Infections

  • Tympanoplasty

• Discharge (otorrhea)

  • External otitis

  • Acute otitis media

• Hearing loss

• Environmental noise

• Tinnitus (ringing in ear) 

• Vertigo (spinning) 

• Self-care behaviours 

• Additional history for infants & children

  • Ear infections 

  • Hearing loss

  • Injury

Objective data: Physical Exam (ear)

• Preparation

  • Position

  • Cleaning the ear canal

• Equipment

  • Otoscope with bright light

External Ear: (Inspect & palpate)

• Size & shape (macrotia vs microtia)

• Skin condition

• Tenderness

  • Tragus, pinna, mastoid process

• External auditory meatus

  • Size, redness, swelling, drainage, cerumen

• Atresia

Testing Hearing:

• Test hearing acuity

  • Conversational speech

  • Whispered voice test

  • Tuning fork tests (Weber, Rinne) - does not yield reliable or precise data

• Vestibular apparatus

  • Romberg test- balance test

THE EYES Subjective Data: Health History

• Vision difficulty (decreased acuity, blurring, blind spots)

• Pain

• Strabismus, diplopia (double vision)

• Watering, discharge (if nurse sees in it is objective)

• History of ocular problems

• Glaucoma

• Glasses or contact lenses

• Self-care behaviours (drinking more water)

• Medication

• Vision loss

The eyes Objective Data: physical examination

• Preparation

  • Position

• Equipment

  • Snellen eye chart

  • Measuring tape

  • Handheld visual screener

  • Opaque card or occluder

  • Penlight

  • Applicator stick

  • Ophthalmoscope

• Central visual acuity

  • Snellen eye chart ( 20 ft away)

• Visual fields

  • Confrontation test

Inspection (eyes): External Ocular Structures

• General

• Eyebrows

• Eyelids and lashes

• Eyeballs

• Conjunctiva and sclera 

• Lacrimal sac

Inspection (eyes): Anterior eyeball structures

• Cornea and lens

• Iris and pupil

  • Size and shape

  • Pupillary light reflex

  • Accommodation

  • PERRLA

Use of Ophthalmoscope:

• Appendage of examiners eye

• Contains set of lenses-unit of strength is diopter

  • Positive dioptres (black) focus on near objects

  • Negative diopter (red) focuses on objects farther away

Positive dioptres

• (black) focus on near objects

Negative diopter

• (red) focuses on objects farther away

Ocular Fundus- inspection:

• Red reflex

• Optic disc

  • Colour

  • Shape

  • Margins

• General background of the fundus

  • Macula

• Retinal vessels

  • Number 

  • Colour

  • Artery-vein ratio

Subjective Data: Health History: NOSE

• Discharge

• Frequent colds (upper respiratory infections)

• Sinus pain or sinusitis

• Trauma

• Epistaxis (nosebleeds)

• Allergies

• Altered sense of smell

Physical Exam: NOSE (Inspect & palpate)

• External nose

• Nasal cavity

  • Holding the otoscope

  • Nasal septum

Physical Exam: SINUS AREAS

• Palpate

  • Frontal and maxillary sinuses

Subjective Data: Health History: MOUTH & THROAT

• sores/lesions

• Sore throat

• Bleeding gums

• Toothache

• Hoarseness

• Dysphagia

• Altered taste

• Smoking, alcohol consumption

• Sleep apnea 

Physical Exam: MOUTH

• Inspect

  • Lips 

  • Teeth and gums

  • Tongue

  • Buccal mucosa

  • Palate and uvula

Physical Exam: THROAT

• Inspect

  • TONSILS- grading from 1+ to 4+

    • Abnormal if tonsils are swollen

  • Use of tongue blade

  • Posterior pharyngeal wall

Objective Data: Physical Exam (mouth)

• Preparation

  • Positioning

• Equipment

  • Otoscope with short, wide-tipped nasal speculum

  • Penlight

  • Two tongue blades

  • Cotton gauze pad (10 by 10 cm)

  • Gloves

  • Occasionally: long-stem light attachment for otoscope

Subjective data:

• what the pt describes

Objective data:

• the information that nurses obtain (vital signs, HR, etc)

Patient database:

• provides evidence to support diagnostic reasoning, it can change

Critical thinking:

• A multidimensional thinking process by which nurses learn to assess and modify diagnoses and treatments, if indicated, before acting

Complete Health History:

• Biographical data

• Source of History

• Reason for seeking care

• Current health/history of current illness

• Past health events

• Family history

• Review of systems

• Functional assessment

Physical Assessment:

• IPPA Inspection, palpation, percussion, and auscultation

  • Use senses of sight, smell, touch, and hearing to gather data

INSPECTION

• Concentrated watching, close/careful scrutiny

• Compare pts right and left sides (symmetrical)

• Use good lighting

• Ensure adequate pt exposure (privacy)

• Will include instruments for specific body systems

  • Otoscope (ear)

  • Ophthalmoscope (eyes)

  • Penlight (dilation of eyes, mouth, throat)

PALPATION

• Use sense of touch to confirm points noted during inspection

• Warm hands first

• Slow hands first

• Slow and systematic

• Calm and gentle

• Start with light & progress to deep palpation

• Encourage pt to use relaxation techniques

• Use intermittent pressure

• Avoid digging in with fingers

• May have to use both hands in bimanual palpation

Characteristics Assessed by Palpation:

• Texture

• Temp

• Moisture

• Organ location/size

• Swelling

• Vibration or pulsation

• Rigidity or spasticity

• Crepitation (grinding feeling in bones, as we age there is a loss of synovial fluid)

• Presence of lumps or masses

• Presence of tenderness or pain

PERCUSSION:

• Tapping skin with short, sharp strokes to assess underlying structures

• Yields palpable vibration and characteristic sounds

  • Location, size density of underlying organs

• Used to map out size/location of organs

• Used to identify density (air, fluid, solid)

• Detects abnormal masses that are superficial

• Elicit pain in an area

• Elicits a deep tendon reflex when done with a percussion hammer

Information Obtained From Percussion:

• Characteristics of percussion notes

  • Resonant

  • Hyperresonant

  • Tympany

  • Dull

  • Flat

Resonant:

• low pitch, hollow sound, heard over lungs

Hyperresonant:

• drum like sound

Tympany:

• high pitch, sounds like a drum.

• Normally heard over fluid-filled organs; stomach, bowel, bladder

Dull:

• indicates solid mass, solid organ or22 fluid

Flat:

• normally heard over solid areas such as bone

AUSCULTATION:

• Use sense of hearing for detecting sounds produced by heart, lungs, and abdomen channelled through a stethoscope

 Diaphragm: stethoscope

• the flat piece, good for hearing high-pitched sounds (breath, lung, normal bowel sounds)

Bell: stethoscope

• the deep, hollow, cuplike shape, good for hearing low-pitched sounds (extra heart sounds and murmurs)

General Principles of Auscultation:

• Quiet examination room

• Clean end piece between pts and ear pieces between users

• Warm end piece in your hand & reach under the clothes to listen

• Take note of artifacts that can be heard

  • E.g., jostling the stethoscope, moving earpieces, body hair, clothing, noisy room

• Ask: what am I hearing? What should I be hearing in this area?

Types of pain

• Nociceptive

  • Somatic

  • Visceral

• Neuropathic

• Referred Pain

• Acute Pain

• Chronic Pain

Nociceptive pain

• caused by TISSUE injury

  • Somatic

  • Visceral

Somatic pain:

• can be superficial in skin & subcutaneous tissue or deep in joints, muscles, tendons or bone

Visceral pain:

• originates from organs such as kidney, intestine, gallbladder, pancreas

  • May be from distension, ischemia, tumor

  • E.g. renal colic, appendicitis, pancreatitis

Neuropathic pain:

• Caused by damage to or disease in the pain pathway/nervous system

  • E.g. nerve trauma from spinal cord injury, herpes zoster damage (shingles), diabetes chronic complication (diabetic neuropathy), after chemo/radiation tx for cancer

  • Described as burning, shooting, stabbing

Referred Pain:

• originates in one location but is felt in another (appendix RLQ but is felt around the umbilical)

Acute Pain:

• short-term, usually following an injury e.g. after surgery, twisted ankle

• Goes away when injury heals

Chronic Pain:

• long-term, >6 month duration

  • Can be malignant (cancer-related) or nonmalignant (arthritis, fibromyalgia, low back pain)

  • Does not go away despite tissue healing

Electronic thermometer:

• wait 20 min before taking pt temp if they had a hot/cold drink

Blood pressure:

• the force of the blood pushing against the vessel wall

Systolic (100-130):

• Maximum pressure felt on the artery during left ventricular contraction or systole

Diastolic:

• Elastic recoil or resting pressure that the blood exerts constantly between each contraction

Pulse pressure:

• difference between the systolic and diastolic pressures, reflects the stroke volume

Mean arterial pressure:

• pressure forcing blood into the tissues, averaged over the cardiac cycle

Influences on BP

• age, sex, ethnocultural background, diurnal rhythm, weight, exercise, emotions, stress

Physiological factors on BP:

• cardiac output, peripheral vascular resistance, volume of circulation blood, viscosity (do not want blood to be thick), elasticity of vessel walls

BP Measurement:

• Equipment includes sphygmomanometer cuff, stethoscope. Always choose right cuff size & length

BP Alterations:

• Hypertension

• Hypotension

• Postural Hypotension

• Orthostatic Hypotension

Hypertension:

• high BP

Hypotension:

• low BP

Postural Hypotension:

• BP that drops more than 10mmHg between sitting and standing

Orthostatic Hypotension:

• systolic BP drops more than 20 mmHg between sitting and standing (caused by bedrest, older age, hypovolemia, some BP or vasodilating meds)

 Infant & Toddler: Head & Chest Circumstances

• Measure head circumference at prominent frontal & occipital bones

  • Newborn 32-38 cm & 2 cm > chest circumference

• Measure chest circumference at nipple line 

  • After age 2, chest circumference > head circumference

  • Compare to growth charts

Layers of the skin

• Epidermis

• Dermis

• Subcutaneous layer

Epidermis

• Stratum germinativum (basal cell layer)

• Stratum corneum (horny cell layer)

Dermis

• Connective tissue (collagen)

• Elastic tissue

Subcutaneous layer

• Adipose tissue

Keratin:

• a protein that gives hair and nails its strength and structure

Bulb matrix:

• base of hair root where new cells are made

Vellus hair:

• fine, faint hair

  • Cover most of body expect palms and soles, dorsa of fingers, umbilicus, the glans penis for men, and inside the labia for women