Health History and Nursing Process

Question 1

What is a Symptom?

Answer 1

Symptom: subjective sensation person feels from disorder

What person says is reason for seeking care is recorded and enclosed in quotation marks to indicate person’s exact words

Question 2

What is a Sign?

Answer 2

Sign: objective abnormality that can be detected on physical examination or in laboratory reports

Question 3

PQRSTU Mnemonic

Answer 3

P = Provocative or palliative
Q = Quality or quantity
R = Region or radiation
S = Severity scale: 1 to 10
T = Timing or onset
U = Understand patient’s perception of problem

Question 4

What is the Assessment process?

Answer 4

Collect Data
Review of clinical record
Health History
Physical examination
Functional assessment
Risk assessment
Review of the literature
Organize Data
Validate Data
Document Relevant Data

Question 5

What is the Diagnosis?

Answer 5

Analyze Data: Compare clinical findings with normal and abnormal variation and developmental events
Interpret data
Identify clusters of clues
What is the problem(s)?
Document diagnosis/problem statement

Question 6

What is the Planning process?

Answer 6

Prioritize problems
Formulate Goals/Desired Outcomes
Set timelines for outcomes
S.M.A.R.T.
Short Term (few hours-days) or Long Term (>1week)
Identify nursing interventions
Individualized & Appropriate
Integrate evidence-based trends and research
Document plan of care

Question 7

What is SBAR?

Answer 7

Situation, Background, Assessment, and Recommendation.

Question 8

What are the four phases of Nociceptive pain?

Answer 8

(1) transduction, (2) transmission, (3) perception, and (4) modulation

Question 9

What is transduction

Answer 9

Initially the first phase of transduction occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery. The periphery includes the skin and the somatic and visceral structures.

Question 10

What is transmission?

Answer 10

In the second phase, known as transmission, the pain impulse moves from the level of the spinal cord to the brain. At the site of the synaptic cleft within the spinal cord are opioid receptors that can block pain signaling with endogenous opioids or with exogenous opioids if they are administered. However, if not stopped, the pain impulse moves to the brain via various ascending fibers within the spinothalamic tract to the thalamus.

Question 11

What is perception?

Answer 11

The third phase, perception, signifies the conscious awareness of a painful sensation. Cortical structures such as the limbic system account for the emotional response to pain, and somatosensory areas can characterize the sensation. Only when the noxious stimuli are interpreted in these higher cortical structures can the sensation be identified as “pain.”

Question 12

What is modulation?

Answer 12

Last, the pain message is inhibited through the phase of modulation. Fortunately our bodies have a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus. If not for pain modulation, the experience of pain would continue from childhood injuries to adulthood.

Question 13

What is visceral pain

Answer 13

Visceral pain originates from the larger internal organs (i.e., stomach, intestine, gallbladder, pancreas). It often is described as dull, deep, squeezing, or cramping. The pain can stem from direct injury to the organ or stretching of the organ from tumor, ischemia, distention, or severe contraction. Examples of visceral pain include ureteral colic, acute appendicitis, ulcer pain, and cholecystitis. The pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the autonomic nervous system (ANS).

Question 14

What is somatic pain

Answer 14

Somatic pain originates from musculoskeletal tissues or the body surface. Deep somatic pain comes from sources such as the blood vessels, joints, tendons, muscles, and bone. Pain may result from pressure, trauma, or ischemia. Cutaneous pain is derived from skin surface and subcutaneous tissues. Deep somatic pain often is described as aching or throbbing, whereas cutaneous pain is superficial, sharp, or burning.

Question 15

What is referred pain?

Answer 15

Pain that is felt at a particular site but originates from another location is known as referred pain. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin.

Question 16

What is acute pain?

Answer 16

Acute pain is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Examples of acute pain include surgery, trauma, and kidney stones.

Question 17

What is chronic pain?

Answer 17

Chronic (persistent) pain is diagnosed when the pain continues for 6 months or longer. Chronic pain can be divided into malignant (cancer-related) and nonmalignant. Malignant pain often parallels the pathology created by the tumor cells.

Question 18

What is neuropathic pain?

Answer 18

Neuropathic pain is pain that does not adhere to the typical and rather predictable phases in nociceptive pain. It is pain due to a lesion or disease in the somatosensory nervous system.13 Neuropathic pain implies an abnormal processing of the pain message from an injury to the nerve fibers. This type of pain is the most difficult to assess and treat.

Question 19

What are the two main processes of pain?

Answer 19

Pathologic pain develops by two main processes: nociceptive (Fig. 11.1) and/or neuropathic processing. It is important to understand how these two types of pain develop because patients present with distinguishing sensations and respond differently to analgesics.

Question 20

What are the three primary categories of communication?

Answer 20

Three primary categories of communication are linguistic, paralinguistic, and metacommunication

Question 21

What is assertive communication?

Answer 21

Assertive communication refers to a process in which positive and negative ideas and feeling are expressed in an open and direct way. Intentionally using assertive communication helps the nurse to advocate for the patient with other health care professionals.

Question 22

Therapeutic Communication

Answer 22

Therapeutic communication is defined as “an interactive process between the nurse and the client that helps the client overcome temporary stress, to get along with other people, to adjust the unalterable, and to overcome psychological blocks which stand in the way of self-realizations.”

Question 23

Intrapersonal communication

Answer 23

Part of an internal perspective, intrapersonal communication takes place within the individual. Often called self-talk, it can be positive and helpful to the person, or it can be negative and self-destructive.9,20 Positive self-talk can be part of an overall mental hygiene regime or part of formalized psychological therapy.

Question 24

Interpersonal communication

Answer 24

Embedded in relationships, interpersonal communication is the verbal and nonverbal interaction that occurs among human beings.20 This interaction can be one-to-one or occur within groups. Interpersonal communication and the resulting relationships begin at birth with the 436infant and parent, and they continue throughout the lifespan, satisfying the human need for connection with others.

Question 25

Reason for seeking care?

Answer 25

Brief spontaneous statement in person’s own words describing reason for visit
Symptom: subjective sensation person feels from disorder
What person says is reason for seeking care is recorded and enclosed in quotation marks to indicate person’s exact words
Sign: objective abnormality that can be detected on physical examination or in laboratory reports

Question 26

History present illness (HPI)

Answer 26

Location
Character or quality
Quantity or severity
Timing
Setting
Aggravating or relieving factors
Associated factors
Patient’s perception

Question 27

What is neuroanatomic Pathway pain?

Answer 27

Pain is a highly complex and subjective experience that originates from the central nervous system (CNS) and/or peripheral nervous system (PNS). Specialized nerve endings called nociceptors are designed to detect painful sensations from the periphery and transmit them to the CNS. Nociceptors are located primarily within the skin; joints; connective tissue; muscle; and thoracic, abdominal, and pelvic viscera. These nociceptors can be stimulated directly by mechanical or thermal trauma or secondarily by chemical mediators that are released from the site of tissue damage.

Question 28

How are pain signals transmitted?

Answer 28

Nociceptors carry the pain signal to the CNS by two primary sensory (or afferent) fibers: Aδ and C fibers (see Fig. 11.1). Aδ fibers are myelinated and larger in diameter; thus they transmit the pain signal rapidly to the CNS. The sensation is localized, short term, and sharp in nature because of the Aδ fiber stimulation. In contrast, C fibers are unmyelinated and smaller, and they transmit the signal more slowly. The “secondary” sensations are diffuse and aching, and they last longer after the initial injury.

Question 29

Peripheral sensory Aδ and C fibers enter the ___________.

Answer 29

Peripheral sensory Aδ and C fibers enter the spinal cord by posterior nerve roots within the dorsal horn by the tract of Lissauer. The fibers synapse with interneurons located within a specified area of the cord called the substantia gelatinosa. A cross section shows that the gray matter of the spinal cord is divided into a series of consecutively numbered laminae (layers of nerve cells) (see Fig. 11.1). The substantia gelatinosa is lamina II, which receives sensory input from various areas of the body. The pain signals then cross over to the other side of the spinal cord and ascend to the brain by the anterolateral spinothalamic tract.