Chapter 3: Vital Signs And Pain Asessment

Question 1

Temperature

Answer 1

Body temperature is regulated by the hypothalamus.

When microorganisms invade the body➞ endogenous pyrogens released which travel to the hypothalamus.

The fever response (pyrexia) is triggered by the production and release of prostaglandins.

The body generates heat by:
-Shivering: rapid contraction and relaxation of the skeletal muscles -> It is important to stop shivering in a febrile child.
-Vasoconstriction: decreases heat loss through the skin -> This can make a child’s hands and feet pale and feel cold.

The body cools by:
-Vasodilation: increases heat loss through the skin; evaporation of perspiration

Question 2

Pulse

Answer 2

Measure of heart rate

Arterial pulse results when the ventricular heart contraction pushes a pressure wave of blood throughout the arterial system.

Apical pulse is recommended in infants and children.

Evaluation of peripheral (femoral and brachial) pulses recommended to evaluate perfusion and hemodynamic stability in infants and children.

Question 3

resp rate

Answer 3

Primary muscles of respiration are the diaphragm and intercostal muscles.

Inspiration
-Diaphragm moves downward.
-External intercostal muscles

Expiration
-Internal intercostal muscles

Intercostal muscles:
-External intercostals increase the anteroposterior chest diameter during inspiration.
-Internal intercostals decrease the lateral diameter during expiration.

Question 4

BP

Answer 4

Peripheral measurement of cardiovascular function

Force of the blood against the wall of an artery as the ventricles contract and relax

Systolic pressure, the force exerted when the ventricles contract, is largely the result of:
-Cardiac output
-Blood volume
-Compliance of the arteries

Blood pressure is highest during systole.

Diastolic pressure is the force exerted by peripheral vascular resistance when the heart is in the filling or relaxed state.

Blood pressure falls to the lowest point during diastole.

The pulse pressure is the difference between the systolic and diastolic pressures.
-For example: If the blood pressure were 120/80 mm Hg, the pulse pressure would be 40 mm Hg.

Question 5

Pain

Answer 5

Pain is a common, uncomfortable sensation and emotional experience associated with actual or potential tissue damage.

Acute pain is sudden, of short duration, and usually associated with surgery, injury, or acute illness.

Chronic pain is persistent, lasting weeks, or months, or longer; usually sustained by a pathophysiologic process.

Neuropathic pain is long-term, associated with damage or dysfunction of the CNS or PNS.

Question 6

Nociception and Pain Transmission

Answer 6

The transmission of pain impulses from the site of injury or tissue damage to the dorsal horn of the spinal cord and brain

Mediated by myelinated A-delta fibers (large) and unmyelinated C-polymodal fibers (small)

Nociceptors transmit pain impulses along A-delta and C fibers to the dorsal horn of the spinal cord.

After the sensory information reaches the dorsal horn of the spinal cord, there is two-way control of nociceptive transmission within the spinal tracts.

Question 7

Pain pathways

Answer 7

Biochemical mediators produced in response to tissue damage help move the pain impulse from the nociceptors (pain receptors) to:
-Dorsal horn of the spinal cord
-Ascending spinal tracts
-Thalamus
-Cerebral cortex

Question 8

Pain modification

Answer 8

Once pain impulses reach the spinal cord they can be modified when other stimuli are present from either the brain or periphery.
-Endorphins
-GABA

Pain impulse transmission may be reduced when nonpain impulses (e.g., ice, massage) compete to transmit sensations along the same spinal pathways to the brain.

Question 9

Response to Pain

Answer 9

Individual response varies widely.

Threshold of response varies.

Tolerance level varies.

Emotions, cultural background, sleep deprivation, previous pain experience, and age are among those factors that have an impact on the perception and interpretation of pain.

Question 10

Pain in special pop

Answer 10

Infants/children
-Increased pulse and respiratory rate
-Lower blood pressure than adults
-Behavioral cues
-Less able to modify pain impulses
-Easily distracted but still have pain
-Different pain scales

Pregnant patients
-Blood pressure changes throughout pregnancy.
-Pregnancy, labor, and delivery pain due to physiologic changes.

Older adults
-No diminished perception of pain
-Decreased pain threshold
-Pain from chronic conditions

Question 11

Present problem

Answer 11

Onset
Date, sudden or gradual, time of day, duration, etc.

Quality
Throbbing, shooting, stabbing, sharp, etc.

Intensity
Pain scale from 1 to 10 appropriate for age

Location
Identify all sites, point to it, travels or radiates

Associated symptoms
Nausea, fatigue, behavior change, irritability

What the patient thinks is causing the pain

Effect of pain on daily activities
Activity limitation, sleep disruption, appetite change, etc.

Effect of pain on psyche
Change in mood or social interactions; poor concentration, can think only about pain; irritability; depression

Pain control measures
Distraction, relaxation, ice, heat, massage, transcutaneous electrical nerve stimulation (TENs), acupuncture

Medications
Opioids, anxiolytics, steroids, antidepressants, acetaminophen, aspirin, nonsteroidal antiinflammatory drugs
Complementary and alternative medicine

Question 12

PMH/SMH

Answer 12

Previous experiences with pain and its effect; typical coping strategies for pain control

Family’s concerns and cultural beliefs about pain: expect or tolerate pain in certain situations
-Genomics may alter effectiveness of opioid pain medication; especially codeine.

Attitude toward the use of opioids, anxiolytics, and other
pain medications for pain control; fear of addiction

Current or past use of illicit substances

Children, pregnant patients, and older adults require a specific pain assessment based on age and condition.

Question 13

Temp exam

Answer 13

Expected range – 97.2° F to 99.9° F (36.2° F to 37.7° C)

Commonly performed:
-Oral
-Rectal
-Axillary
-Tympanic
-Forehead

Fever considered T >100.4° F (38° C) (99° F axillary [37.2° C])

0 to 90 days of life with fever needs immediate evaluation.

Over 90 days of life T>105° F (40.5° C) needs immediate evaluation.

Question 14

Pulse exam

Answer 14

Apical pulse preferred in infants and children

Evaluate children for murmurs.

Palpate pulses over carotid, brachial, radial, femoral,
popliteal, dorsalis pedis, posterior tibial arteries.

Pulse varies based on age during childhood.

Count pulsations for 30 seconds (multiply by 2).

Average adult pulse ranges between 60 and 100 beats/min.

Determine steadiness of the heart rate.
-Should be regular
-If an irregular rate is detected, count for a full 60 seconds.
-Also note the contour (wave form) and amplitude (force) of each pulsation.

Question 15

Resp rate exam

Answer 15

Assess the respiratory rate by inspecting the rise and fall of the chest or auscultation.

Count the number of breaths (inspiration and expiration) that occur in 1 minute.
-30 seconds and multiply by 2

Normal respiratory rate in children varies depending on
age.

Normal adult respiratory rate is 12 to 20 breaths/min.

Evaluate the child’s work of breathing.
-Increased respiratory rate
-Retractions (note location)
-Nasal flaring
-Stridor/ grunting

Tachypnea is a faster than normal respiratory rate.

Bradypnea is a slower than normal respiratory rate.

Question 16

BP exam

Answer 16

Child:
-Use the appropriate sized cuff. -> Largest cuff that will fit on the upper arm and leave room for the stethoscope head (NHLBI)
-Routine BPs start at age 3.

Adult:
-Most often measured in the right arm over the brachial artery when the patient is seated
-Blood pressures taken in supine position tends to be lower than those taken in sitting position.
-Sounds -> Phases 1 to 5. Korotkoff sounds
-Levels -> Healthy, prehypertensive, hypertensive. High blood pressure and hypertension are diagnosed based on several measurements taken over time.
-Determine palpable systolic pressure.
-Deflate cuff completely.
Re-inflate the cuff until it is 20 to 30 mm Hg above the palpable systolic blood pressure.

Deflate the cuff slowly 2 to 3 mm Hg per second.

Use the bell of the stethoscope.

Two consecutive beats indicate the systolic pressure reading.

Note the point at which the initial crisp sounds become muffled: this is the first diastolic sound.

Note the point at which the sounds disappear: this is the second diastolic sound.

The two blood pressure readings recorded are the first systolic and the second diastolic sounds (e.g., 110/68).

Repeat the process in the other arm.

May vary by as much as 5 to 10 mm Hg

Question 17

HTN

Answer 17

Child: HTN related to gender and age

Adult: Defined as a blood pressure consistently at 140/90 mm Hg or higher

For essential hypertension, its pathologic origin is poorly understood.

For secondary hypertension, potential causes are renal disease, renal artery stenosis, aldosteronism, thyroid disorders, coarctation of the aorta, or pheochromocytoma.

Subjective data: headache, dyspnea, etc.

Objective: end-organ damage

Question 18

Pain assessment

Answer 18

When the chief complaint is pain, the location and related symptoms may assist in the diagnosis of a patient’s condition.

If the pain is related to a diagnosed condition, assessment of its character and intensity is necessary for pain control.

Remember that there may be more than one cause of pain.

Pain is the fifth vital sign.

Assess pain as appropriate for infants, children, pregnant patients, and older adults.

Question 19

Self-report pain rating scales

Answer 19

Pain is what the patient says it is.

Consistent use of a particular scale will contribute to consistent interpretation.

Encourage patient to express painful feelings and to use a pain scale to report level of pain.

Pain behaviors
-Guarding
-Facial mask of pain
-Vocalizations
-Body movements
-Vital sign changes
-Pallor and diaphoresis
-Pupil dilation
-Dry mouth
-Decreased attention span, greater confusion, irritability

Question 20

Neuropathic pain

Answer 20

A form of chronic pain caused by a primary lesion or dysfunction of the central nervous system that persists beyond expected after healing

Potential causes include postherpetic neuralgia, diabetic peripheral neuropathy, trigeminal neuralgia, or radiculopathy.

Damaged peripheral nerves fire repeatedly.

Subjective: burning, shooting, stabbing, etc.

Objective: self-report, sensory loss, pain distribution, etc.

Question 21

Complex pain syndrome

Answer 21

A syndrome in which regional pain extends beyond a specific peripheral nerve injury in an extremity with motor, sensory, and autonomic changes

No relationship between the original trauma severity and the severity and cause of the symptoms

Cause is unknown.

Question 22

Potential causes of secondary hypertension include all of the following except:

Increased water intake
Renal artery stenosis
Thyroid disorders
Coarctation of the aorta

Answer 22

ANS: A

Rationale: Potential causes for secondary hypertension include renal disease, renal artery stenosis, aldosteronism, thyroid disorders, and coarctation of the aorta.

Question 23

The primary muscles of inspiration are:

Diaphragm and intercostal
Ribs and sternum
External intercostal
Internal intercostal

Answer 23

ANS: C

Rationale: The external intercostal muscles increase the AP chest diameter during inspiration and the internal intercostal decrease the lateral diameter during expiration.

Question 24

The perception of pain:

Is the same across cultures
Does not apply to neonates
Is predictable with the same circumstances
Is impacted by emotions and quality of sleep

Answer 24

ANS: D

Rationale: The perception of pain is variable and is impacted by emotions, cultural background, sleep deprivation, previous pain experience, and age. Perception of pain is different among cultures and does apply to neonates