HA ch 6 10

What is the purpose of health assessment?

Collect information to guide patient care.

What is the first step in the assessment process?

Gather subjective data.

What is subjective data?

Information reported by the patient.

What is objective data?

Information observed or measured by the nurse.

What is the main source of subjective data?

Patient.

What is the main source of objective data?

Nurse's assessment.

What is a chief complaint?

Main reason for seeking care.

How should a chief complaint be documented?

Patient's exact words in quotation marks.

What does ROS stand for?

Review of systems.

What is a review of systems?

Patient-reported symptoms from each body system.

What is the purpose of a health database?

Records past and current health information.

What is a baseline health assessment?

Starting point for comparing future findings.

What is patient advocacy?

Supporting and protecting patient needs.

What is an example of subjective data?

Patient reports pain.

What is an example of objective data?

Blood pressure measurement.

What assessment techniques collect objective data?

Inspection, palpation, auscultation.

What is the difference between subjective and objective data?

Patient reports versus nurse observations.

What is pain?

Personal experience of discomfort.

Who determines how much pain a patient has?

Patient.

What is the main rule of pain assessment?

Pain is whatever the patient says it is.

Why should nurses believe patient pain reports?

Pain is subjective.

Should nurses judge whether a patient's pain is real?

No.

Why is pain management individualized?

Each patient experiences pain differently.

Is pain management the same for every patient?

No.

Why do many patients seek healthcare?

Pain.

What are the three pain types discussed in the guide?

Acute, chronic, referred.

What is acute pain?

Short-term pain from injury or tissue damage.

What commonly causes acute pain?

Illness, injury, or surgery.

Where is acute pain commonly assessed?

Surgery, emergency, primary care.

What is the usual duration of acute pain?

Short-term.

What is chronic pain?

Pain lasting beyond normal healing.

How long can pain last before being considered chronic?

More than 3–6 months.

What does chronic pain commonly affect?

Quality of life.

How can chronic pain affect employment?

Lost income and productivity.

Why can chronic pain be expensive?

Ongoing treatment and lost income.

What is a nonmedication treatment for chronic pain?

Deep breathing.

What is referred pain?

Pain felt away from its actual source.

Why is referred pain important?

Pain location may differ from the affected organ.

Where can heart pain be felt in the front of the body?

Chest, left arm, shoulder, neck.

Where can heart pain be felt in the back?

Between shoulder blades.

What does interscapular mean?

Between shoulder blades.

Where can lung and diaphragm pain be felt in the front?

Neck and shoulder.

Where can lung and diaphragm pain be felt in the back?

Upper shoulder and trapezius.

What is the trapezius?

Muscle across upper back and neck.

Where can liver pain be felt in the front?

Right upper abdomen and below collarbone.

Where can liver pain be felt in the back?

Right upper back and shoulder blade.

What does subclavicular mean?

Below the collarbone.

Where can stomach pain be felt in the front?

Upper middle abdomen.

Where can stomach pain be felt in the back?

Middle thoracic spine.

Where can pancreatic pain be felt in the front?

Upper middle abdomen.

What is the epigastric region?

Upper middle abdomen.

Where can small intestine pain be felt?

Around belly button.

What is the umbilical region?

Area around belly button.

Where can appendix pain be felt?

Right lower abdomen.

What does RLQ stand for?

Right lower quadrant.

Where can colon pain be felt?

Lower abdomen.

Where can bladder pain be felt in the front?

Lower middle abdomen.

Where can bladder pain be felt in the back?

Sacral area and upper inner thighs.

What does suprapubic mean?

Above the pubic bone.

Where can ureter pain be felt?

Lower abdomen or groin.

Where can kidney pain be felt?

Flank, lower back, or groin.

What is the flank?

Side of the back near kidneys.

Where can ovarian pain be felt?

Side of lower abdomen.

What is the sacral region?

Lower back near tailbone.

What are objective signs of acute pain?

High BP, fast pulse, sweating, guarding.

What happens to blood pressure during acute pain?

Increases.

What happens to heart rate during acute pain?

Increases.

What is tachycardia?

Fast heart rate.

How can acute pain affect breathing?

Shallow respirations.

What are shallow respirations?

Short, less deep breaths.

What is diaphoresis?

Excessive sweating.

What is pallor?

Unusual paleness.

What is facial grimacing?

Painful facial expression.

What happens to pupils during acute pain?

Dilate.

What does pupil dilation mean?

Pupils become larger.

What is restlessness?

Difficulty staying still.

What is guarding?

Protecting a painful body part.

Why might a patient guard an injured area?

To prevent more pain.

What facial sign may indicate pain?

Grimacing.

What skin signs may indicate acute pain?

Sweating and pallor.

What cardiovascular signs may indicate acute pain?

High BP and tachycardia.

What respiratory sign may indicate acute pain?

Shallow breathing.

What behavioral signs may indicate acute pain?

Restlessness and guarding.

Do all patients show physical signs of pain?

No.

Can a patient have pain without an increased heart rate?

Yes.

What is the most important source for pain intensity?

Patient's report.

Does normal aging automatically reduce pain sensation?

No.

Is chronic pain common in older adults?

Yes.

Should pain in older adults be dismissed as normal aging?

No.

How should nurses communicate with older adults who have hearing problems?

Face them directly.

What hearing device should older adults use if needed?

Hearing aids.

How can nurses help older adults with poor vision?

Large-print materials.

What should written materials for visual impairment include?

Large font and clear spacing.

What visual device should patients use if prescribed?

Glasses.

Why should older adults have extra response time?

May need longer to process questions.

How should nurses adjust the pace of questions for older adults?

Allow extra time.

Are there proven racial differences in physical pain perception?

No.

What can cause unequal pain treatment among racial groups?

Unconscious bias.

What is unconscious bias?

Unrecognized assumptions affecting decisions.

How can unconscious bias affect pain assessment?

Pain may be underestimated.