GENERALIZED QUESTIONS ABOUT HA Flashcards
This is a mnemonics that nurse to explore symptoms, signs or health concerns
COLDSPA
Character - Describe the sign or symptom (feeling, appearance, sound, smell, or taste if applicable). “What does the pain feel like?”
Onset -When did it begin? “When did this pain start?”
Location - Where is it? Does it radiate? Does it occur anywhere else? “Where does it hurt the most? Does it radiate or go to any other part of your body?”
Duration- How long does it last? Does it recur? “How long does the pain last? Does it come and go or is it constant?”
Severity - How bad is it? How much does it bother you?
“How intense is the pain? Rate it on a scale of 1 to 10.”
Pattern - What makes it better or worse?
“What makes your back pain worse or better? Are there any treatments you’ve tried that relieve the pain?”
Associated factors - /How it Affects the client
What other symptoms occur with it? How does it affect you?
\ “What do you think caused it to start?
Do you have any other problems that seem related to your back pain?
what is PQRST
Proactive/Palliative
Quality
Radiates
Severity
Timing
The client should sit upright on the side of the examination table. This position is good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and
upper extremities. This position is also useful because it permits full expansion of the lungs and it allows the examiner to assess symmetry of upper body parts
Sitting Position
Ask the client to lie down with the legs
together on the examination table. A small pillow may be placed under the head to promote comfort. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities
Supine position
The client lies down on the examination table or bed with the knees bent, the legs separated, and the feet flat on the table or bed. Areas that may be assessed with the
client in this position include head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The abdomen should not be assessed because the abdominal muscles are contracted in this position.
Dorsal Recumbent
The client lies on the right or left side with the lower arm placed behind the body and the upper arm flexed at the shoulder and elbow. The lower leg is slightly flexed at the knee while the upper leg is flexed at a sharper angle and pulled forward.
This position is useful for assessing the rectal and vaginal areas.
SIMS POSITION
The client ___________ in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia.
Standing position
The client lies down on the abdomen
with the head to the side.
Used to assess hip joint.
The back can also be assessed with the client in this position. Clients with cardiac and respiratory problems cannot tolerate this position.
Prone position
The client kneels on the examination table
with the weight of the body supported by the chest and knees. A 90-degree angle should exist between the body and the hips. The arms are placed above the head, with the head turned to one side.
USEFUL FOR EXAMINING THE RECTUM
KNEE-CHEST POSITION
The client lies on the back with the hips at the edge of the examination table and the feet supported by stirrups.
USED TO EXAMINE FEMALE GENETALIA, REPRODUCTIVE TRACTS, AND RECTUM
LITHOTOMY POSITION
loud, low, hallow sounds in normal lung.
heard over part air and part solid
Resonance
very loud, low, booming sound. we can hear this with lung emphysema. Hears over mostly air
Hyper-resonance
Loud, high, drum-like. Puffed-out heek, gastric bubble. Heard over air
Tympany
Medium, mnoderate, thud-like sound in diaphragm, pleural effusion, liver.
Heard over more solid tissue
Dullness
Soft, high, flat that is heard over very dense tissue. Muscle bone, sternum, thigh
Flatness
refers to the clients level of cognitive functioning (thinking, knowledge, problem solving) and emotional function.
Mental Status
is an essential part of one’s total health and is more than just the absence of mental disabilities or disorders.
mental health
efficient screening test to detect
alcohol dependence in trauma center populations
CAGE SELF ASSESSMENT TEST
a set of related conditions associated with the consumption of mind- and behavior-altering substances that have
negative behavioral and health outcomes.”
Substance abuse
assessment guide can be used to
assess the likelihood of a suicide attempt
SAD PERSONS Suicide Risk Assessment
for clients who are at high risk for rapid deterioration of the nervous system
Glasgow Coma Scale GCS
refers to whatever a person is
sensing, thinking about, or experiencing at any given moment.
consciousness
normal body temp
36.5 to 37.7 degree Celsius
Normal pulse rate
60 to 100 beats per minute
normal respiration rate
12 to 16 breaths per minute
blood pressure
120/80
A pulse rate grater than 100 beats/min. May occur with fever, certain medications, stress, and other abnormal states,
such as cardiac dysrhythmias.
tachycardia
Pulse rate less than 60 beats/min.
Sitting or standing
for long periods may cause the blood to pool and decrease the
pulse rate. Heart block or dropped beats can also manifest
Bradycardia
A pulse pressure lower than 30 mmHg or higher than 50 mmHg may indicate
cardiovascular disease
“an unpleasant sensory and emotional
experience, which we primarily associate with tissue damage or describe in terms of such damage
Pain
The source of pain
stimulates peripheral nerve endings
nociceptors
pain begins when a mechanical, thermal,
or chemical stimulus results in tissue injury or damage stimulating the nociceptors
Transduction
initiate a painful stimulus that results in an inflammatory process
Noxious Stimuli
Emotional pain or mental pain; refers to pain originating from the person’s psychological dimension and has been found to underlie suicidal behavior
Psychological pain
The process of somatization, when psychological pain becomes physical
Psychosomatic or psychogenic pain
Involves in transferring or converting uncomfortable feelings into physical symptoms
Somatization
Pain caused by nerve receptors detecting harmful stimuli. The receptors react to mechanical, chemical, or thermal stimuli that may cause damage to skin, muscles, bones, or connective tissue (Smith, 2018). is the most common type of pain.
Nociceptive pain
Results from damage or dysfunction of any level of the nervous system
Neuropathic pain
Has two aspects: inflammatory and immune responses accompanying and causing both nociceptive and neurologic pain, and inflammatory pain syndromes, such as back pain, shoulder pain, arthritis, rheumatoid arthritis, fibromyalgia, and migraine
Inflammatory pain
Occurs when stimuli in the tissues (skin, muscles, joints, skeleton, connective tissue) are activated. Stimuli such as force, temperature, vibration, and swelling activate the nerve receptors and produce a sensation of cramping gnawing, aching, or sharp pain
Somatic pain
Occurs when nerves in the internal organs in the chest, abdomen, intestines, or pelvis are stimulated.
It feels vague, not localized, with a sensation of a deep squeeze, pressure, or aching
Visceral Pain
Generated by stimuli at the nerve toot at its connection to the spinal nerves.
Radicular Pain
A sensation of pain in a body region distant from the actual source of the painful stimulus.
Referred Pain
pain in a part of the body that has been removed, such as a leg
Phantom pain
Is more than one type of pain.
include nerve pain, bone pain, tissue pain, and the pain may be referred or phantom (pain in a part of the body that has been removed).
Cancer pain
