Lab 5 Flashcards
Wong-Baker pain assessment
Uses faces to determine level of pain
Used of people over 3 years of age
When should you assess for pain
On admission
Whenever there is a change in behaviour (take vitals too if this happens)
Q1H when pain indicators suggest goals haven’t been met yet
During an analgesic test (Q1H x 12, then Q2Hx12, then 4)
Sign
Objective, measurable
Protecting area, grimacing, broken bone
Symptom
Subjective, not measurable
Nausea
Pain assessment components
OPQRSTUV
Onset
Provoking
Quality
Region/radiation
Severity
Treatment
Understanding
Values
Not in correct order
Onset
When did the paint start
Provoking/palliation
What makes it worse? Better?
Quality
Description of the pain
Region/radiation
Location of pain, does it travel?
Severity
0-10 scale
Treatment / timing
Have you felt this before? Do you do anything to make it better? Does it work?
Understanding
Do you know why you’re in pain?
Values
Could be at end of life care and meds make them sleepy. Can choose not to take them to see family
Why do we ask for pain assessment at the start of shift
To establish a baseline of pain
Levels of wheelchair transfer
Independent - no help
Standby assist - be available
1 person assist - help out
Important thing to remember during movement and positioning
Keep centre of gravity within base of support
Transitioning with weakness
Transition on same side of weakness.
Left side weak, do transfer from left side of bed
Remember for stroke - weakness is on opposite side
Lordosis
Exaggeration of anterior convex curvature of the spine
Kyphosis
Exaggerated convex curvature in thoracic spine
Think of Igor
Scoliosis
Lateral curvature of the spine
Unequal heights of hips and shoulders
Foot drop
Inability to dorsiflex and evert foot due to peroneal nerve damage
Disease atrophy
Tendency of cells and tissues to reduce in size and function in response to prolonged time of inactivity
Atelectasis
Collapse of alveoli
Hypostatic pneumonia
Inflammation of the lungs from pooling of secretions
Orthostatic hypotension
A drop in BP or 20 mmhg systolic or 10 mmhg diastolic
Thrombus
Accumulation of platelets, clotting factors, etc attached to the wall of a vessel
Joint contracture
Fixation of a joint
Pressure injury
Localized damage to the skin do to prolonged time of ischemia
Physiological hazards of immobility: metabolic
Slower wound healing
Muscle atrophy
Edema
Physiological hazards of immobility: respiratory
Dyspnea, wheezing, increased respiratory rate, shallow breathing
Physiological hazards of immobility: cardiovascular
Edema
Increased heart rate
Orthostatic hypotension
Physiological hazards of immobility: musculoskeletal
Decreased ROM
Joint contracture
Muscle atrophy
Physiological hazards of immobility: elimination
Decrease urine output
Improper urine output (cloudy, etc)
Irregular BMs
Physiological hazards of immobility: skin
Impaired skin integrity
