Assessment Flashcards
Recent injury
Acute pain
Constant pain for more than 6 months
Chronic nonmalignant pain
Compression of peripheral nerves
Cancer pain
Superficial pain
Cutaneous pain
Abdominal cavity, thorax, cranium
Visceral pain
Ligaments, tendons, bones, blood vessels, nerves
Deep somatic pain
Perceived at source and other tissues
Radiating pain
Body areas away from pain source
Referred pain
Nerves left by a missing body part
Phantom pain
Nervous system is damaged
Neuropathic pain
High resistance to pain relief
Intractable pain
General term for uncomfortable sensations and stems from activation of nervous system
Pain
Range of pain
Annoying to debilitating
Fifth vital sign
Pain
Multidimensional observational assessment of a patient’s experience of pain
Pain assessment
Points of pain
Pain history
Location of pain
Intensity of pain
Cognitive development and understanding of pain
1 min and 5 mins after birth
APGAR score
Who formulated APGAR
Dr. Virginia Apgar in 1952
Quick assessment of physical condition of newborn
APGAR score
What is APGAR
Appearance - Color
Pulse- HR
Grimace - Reflex/Irritation
Activity - Muscle Tone
Respiration - Respiratory
MMDST
Metro Manila Development Screening Test
Test normalcy of MMDST in what age
6 1/2 yrs and below
PH ver. of?
Denver Developmental Screening Test (DDST)
Who modified MMDST
Dr. Phoebe Williams
Sectors of development of MMDST
Personal - Social
Fine Motor Adaptive
Language
Gross Motor
Tasts that indicate the child’s ability to get along
Personal - social
Ability to see and use hands to pick up object
Fine Motor Adaptive
Ability to hear, speak, and follow
Language
Ability to sit, walk, jump
Gross Motor
GPTPAL
Gravida/Gravidity
Para
Term
Preterm
Abortion
Living
Number of pregnancies
Gravida
Number of delivered at 20 weeks gestation
Para
Delivery of pregnancy 38-42 weeks
Term
Delivery after 20 weeks and before 38
Preterm
Termination prior to 20th week
Abortion
Number of living children
Living
Process of GPTPAL
Assess contraction
Fundal height
Leopold’s maneuver
Last menstrual period
IAPP
Inspection
Auscultation
Palpation
Percussion
Observe normal/abn findings
Inspection
Requires stethoscope
Auscultation
Classification of auscultation
Intensity
Pitch
Duration
Quality
What pitch are these for?
Diaphragm
Bell
High pitch
Low pitch
Parts of hands to touch
Palpation
Parts of hands to use on palpation
Finger pads
Ulnar/Palmar
Dorsal surface
Types of Palpation
Light
Moderate
Deep
Bimanual
Dominant hand and palpate in circular motion
Light
1-2 cm with dominant hand using circular motion
Moderate
2-5 cm, dominant hand for palpation and non dominant for pressure
Deep
Use two hands
Bimanual
Tapping body parts to use sound waves
Percussion
Assessment used in percussion
Eliciting pain
Determining location, size, and shape
Determining density
Detect abn masses
Types of percussion
Direct
Blunt
Indirect/Mediate
Direct tapping using one/two fingertips that indicate tenderness
Direct
One hand flat to skin and other hand to strike the back of hand
Blunt
Middle finger of non dominant hand and tap by the other hand
Indirect/Mediate
READ
As density increases, tone decreases
11 Classifications of Pain
Acute
Chronic nonmalignant
Cancer
Cutaneous
Visceral
Deep somatic
Radiating
Referred
Phantom
Neuropathic
Intractable
Assess an individual’s functional status and ability to perform self care tasks independently.
KATZ Index
6 key areas in KATZ index
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Ordinal scale that measures functional independence in the domains of personal care and mobility in patients with chronic and disabling conditions in rehabilitation setting.
Barthel Index
Measurement tool to evaluate the level of functional independence in the general elderly population.
Lawton Brody IADL
Who formulated DDST?
Dr. William K. Frankenburg
Pain assessment for 3 to 18 years old self report
Wong-Baker FACES Pain Rating Scale
Pain assessment for 8 years and older
Visual Analog Scale
Pain assessment useful for cognitively impaired and critically ill children. Each category is scored on a 0 to 2 scale.
FLACC Scale
Five types of pain assessment tools
Wong-Baker FACES Pain Rating Scale
Visual Analog Scale
FLACC Scale
Numeric Pain Scale
Simple Descriptive Pain Intensity Scale
