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Initial Health History Review, Pain Management, and Cultural Competence

General Survey, Questions, and History

  • Reviewing Initial Health History (for reoccurring patients):

    • Purpose: To ensure nothing has changed since the last visit and to establish a normal baseline for the patient.

    • Information reviewed:

      • Subjective information (patient's reported feelings).

      • Demographics (e.g., if they moved).

      • Past and present conditions (new conditions or previously undisclosed past conditions).

      • Family medical history (may have changed).

      • Social history (may have changed).

      • Medications (current prescriptions or changes).

    • Action: Document any changes observed during the review.

Patient Preparation and Equipment

  • Patient Preparation: Prepare the patient for the assessment.

  • Equipment for Vitals: Gather all necessary equipment:

    • Thermometers

    • Blood pressure cuffs

    • Stethoscope

    • Watch with a sweeping second hand (digital watches like Apple Watch may require frequent wrist turning).

Validation, Documentation, and Professional Assistance

  • Validate and Document Findings: Accurately record all vital sign measurements and observations.

  • Seek Professional Help: If needed, ask for assistance from another healthcare professional.

  • Compare Data: Analyze current data against previous records or expected norms.

Pain: The 5th Vital Sign

  • Definition: Pain is subjective; it is whatever the patient says it is. Healthcare providers then seek evidence and data to support the patient's report.

    • Example: A paper cut might be the most painful experience for an individual.

  • Physiological Responses to Unmanaged Pain (Stress Response):

    • Triggers the sympathetic nervous system, leading to a physiological response.

    • If not dealt with properly, chronic pain can lead to:

      • Anxiety and fear

      • Feelings of hopelessness

      • Lack of sleep

      • Thoughts of suicide

  • Observable Physiological Responses to Pain:

    • Patient's focus on the pain.

    • Crying, moaning, or groaning.

    • Distorted facial expressions.

    • Decreased cognitive function and mental confusion (in severe pain).

    • Altered temperament (e.g., being snippy or rude if usually nice).

    • Dilated pupils.

    • Increased vital signs:

      • Heart rate

      • Blood pressure

      • Temperature

    • Decreased gastric and intestinal motility (body not focused on digestion).

    • Decreased urinary output.

    • Depression of immune functions (increased susceptibility to infections).

    • Increase in fight-or-flight response hormones.

    • Hyperglycemia (blood glucose increases during fight-or-flight).

    • Muscle spasms.

    • Perspiration.

Assessing Pain

  • Key Questions to Ask:

    • Cause/Etiology: What is causing the pain? When did it start (onset)?

    • Duration: How long has it been going on?

    • Intensity: What does it feel like (e.g., stabbing, aching, burning, dull ache)?

    • Location: Where is the pain?

    • Severity: How severe is it?

Causes of Pain

  • Nociceptive Pain (Inflammatory Pain): Caused by damage to non-nervous tissue, often due to inflammation.

    • Examples: Post-operative pain, arthritis, lower back pain from a muscle pull, ischemia, infections, trauma.

  • Neuropathic Pain: Caused by a lesion or disease affecting the Central Nervous System (CNS) or Peripheral Nervous System (PNS).

    • Examples: Spinal root compression, central pain, diabetes (diabetic neuropathy), HIV.

  • Mixed Type Pain: A combination of nociceptive and neuropathic pain.

    • Examples: Shingles, migraines, certain types of back pain.

Duration and Etiology of Pain

  • Acute Pain: From a recent injury or sudden illness.

  • Chronic Pain: Persists for longer than expected, typically over 1 month.

    • Non-malignant Chronic Pain: Not life-threatening (e.g., chronic back pain).

    • Malignant Chronic Pain: Associated with life-threatening conditions (e.g., various types of cancers).

  • Intractable Pain: Pain that is not effectively managed by standard medications.

Classifications of Pain

  • Nociceptive Pain Types:

    • Cutaneous Pain:

      • Origin: Skin and superficial tissues.

      • Characteristics: Usually well-localized, classified as acute pain, sharp sensation.

      • Example: A paper cut.

    • Visceral Pain:

      • Origin: Internal organs.

      • Characteristics: Often felt as a dull ache or pressure.

    • Deep Somatic Pain:

      • Origin: Muscles, bones, joints, tendons, ligaments.

      • Characteristics: Poorly localized, similar to visceral pain, often described as a dull ache.

  • Other Pain Classifications:

    • Radiating Pain: Pain that travels from its primary source to another location along a nerve pathway.

      • Examples: Heart attack pain radiating to the arm or shoulder in men, or the jaw in women. The primary source is the heart, but the pain extends to other areas.

    • Referred Pain: Pain that is felt at a location different from the injured or diseased organ, due to shared nerve pathways.

      • Example: Appendicitis where pressing on the appendix area causes pain on the opposite side of the abdomen. The problem is the appendix, but the pain perception is elsewhere.

      • Note: It is crucial to understand the distinction between radiating and referred pain.

    • Phantom Pain: Pain experienced in a limb that has been amputated.

      • Mechanism: Even after amputation, the nerves from the removed limb remain and are tucked into the remaining body part. These nerves continue to send signals to the brain, which interprets them as pain from the missing limb.

Dimensions of Pain

  • Visible/Physiological: Observable signs such as increased vital signs and sweating.

  • Sensory: Relates to the location, intensity, and quality of pain. External environmental factors (e.g., bright lights, noise) can heighten sensory perception of pain.

  • Behavioral: Observable actions like moaning, groaning, or facial expressions. It's important to recognize that culture significantly affects how individuals display pain; some cultures may suppress outward expressions of pain.

  • Cognitive: Encompasses the patient's thoughts, beliefs, and attitudes towards pain. This includes whether they believe it's acceptable to show pain and what they perceive the pain to mean.

  • Affective: Involves emotional responses such as sadness, nervousness, anxiety, or frustration related to the pain.

  • Spiritual: Pertains to any spiritual beliefs that may impact the patient's coping with pain and suffering. Nurses should support and encourage these beliefs, whatever they may be.

Pain Perception and Assessment Approach

  • Variability: Pain perception differs across age groups (children, adults, geriatric patients) and cultures.

  • Patient-Centered Language: When assessing pain, use the patient's exact words in direct quotes to describe their pain.

  • Comprehensive Assessment Details: Include:

    • Location, intensity, quality, and pattern of pain.

    • Precipitating factors (what makes it better or worse).

    • Any pain relief methods used.

    • Impact on Daily Activities: Does the pain affect their ability to work, socialize, or perform normal daily tasks?

    • Coping Strategies: How do they cope (e.g., music, distraction, or maladaptive methods like drugs and alcohol, which require counseling).

    • Emotional Responses: Note any changes in emotional demeanor, such as lashing out.

Pain Assessment Tools: The 0-10 Scale

  • Adult Pain Assessment Tool: The 0-10 pain scale is commonly used due to its clarity, ease of use, and reliability.

    • 0: No pain at all.

    • 10: Worst pain possible.

  • Intervention Based on Score: Clinical interventions are guided by the patient's reported pain level.

    • Example: For mild pain (e.g., 2), Tylenol might be ordered. For severe pain (e.g., 9), a stronger analgesic like Percocet might be indicated. The medication should match the severity of pain.

  • Process: Check, validate, and ask the patient about their pain openly.

Culture and Diversity in Healthcare

  • Impact of Culture: Culture profoundly impacts health, how people communicate, their rituals, beliefs, and behaviors related to health and illness.

  • Nurse's Role: It is the nurse's responsibility to respect diverse cultural practices, help patients manage their medical illnesses, and support the maintenance of their cultural traditions.

Essential Definitions (for exams)

  • Culture: A shared system of values, beliefs, and learned patterns of behavior that define a group's way of living.

  • Cultural Norms: Learned behaviors that are perceived as appropriate or inappropriate within a specific culture.

    • Example: Shaking hands when meeting someone in the United States is a cultural norm; coming to class naked is not.

  • Cultural Values: Learned beliefs about what is considered good or bad within a culture.

    • Example: Most cultures view cannibalism as bad, while some historical or isolated cultures may not.

  • Ethnocentrism: The belief that one's own culture is superior to others, often stemming from limited interaction with diverse cultures, leading to a restricted worldview.

    • Example: A tourist calling foreign food