Lab 5

Question 1

Wong-Baker pain assessment

Answer 1

Uses faces to determine level of pain

Used of people over 3 years of age

Question 2

When should you assess for pain

Answer 2

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)

Question 3

Sign

Answer 3

Objective, measurable

Protecting area, grimacing, broken bone

Question 4

Symptom

Answer 4

Subjective, not measurable

Nausea

Question 5

Pain assessment components

Answer 5

OPQRSTUV

Onset
Provoking
Quality
Region/radiation
Severity
Treatment
Understanding
Values

Not in correct order

Question 6

Onset

Answer 6

When did the paint start

Question 7

Provoking/palliation

Answer 7

What makes it worse? Better?

Question 8

Quality

Answer 8

Description of the pain

Question 9

Region/radiation

Answer 9

Location of pain, does it travel?

Question 10

Severity

Answer 10

0-10 scale

Question 11

Treatment / timing

Answer 11

Have you felt this before? Do you do anything to make it better? Does it work?

Question 12

Understanding

Answer 12

Do you know why you’re in pain?

Question 13

Values

Answer 13

Could be at end of life care and meds make them sleepy. Can choose not to take them to see family

Question 14

Why do we ask for pain assessment at the start of shift

Answer 14

To establish a baseline of pain

Question 15

Levels of wheelchair transfer

Answer 15

Independent - no help
Standby assist - be available
1 person assist - help out

Question 16

Important thing to remember during movement and positioning

Answer 16

Keep centre of gravity within base of support

Question 17

Transitioning with weakness

Answer 17

Transition on same side of weakness.

Left side weak, do transfer from left side of bed

Remember for stroke - weakness is on opposite side

Question 18

Lordosis

Answer 18

Exaggeration of anterior convex curvature of the spine

Question 19

Kyphosis

Answer 19

Exaggerated convex curvature in thoracic spine

Think of Igor

Question 20

Scoliosis

Answer 20

Lateral curvature of the spine
Unequal heights of hips and shoulders

Question 21

Foot drop

Answer 21

Inability to dorsiflex and evert foot due to peroneal nerve damage

Question 22

Disease atrophy

Answer 22

Tendency of cells and tissues to reduce in size and function in response to prolonged time of inactivity

Question 23

Atelectasis

Answer 23

Collapse of alveoli

Question 24

Hypostatic pneumonia

Answer 24

Inflammation of the lungs from pooling of secretions

Question 25

Orthostatic hypotension

Answer 25

A drop in BP or 20 mmhg systolic or 10 mmhg diastolic

Question 26

Thrombus

Answer 26

Accumulation of platelets, clotting factors, etc attached to the wall of a vessel

Question 27

Joint contracture

Answer 27

Fixation of a joint

Question 28

Pressure injury

Answer 28

Localized damage to the skin do to prolonged time of ischemia

Question 29

Physiological hazards of immobility: metabolic

Answer 29

Slower wound healing
Muscle atrophy
Edema

Question 30

Physiological hazards of immobility: respiratory

Answer 30

Dyspnea, wheezing, increased respiratory rate, shallow breathing

Question 31

Physiological hazards of immobility: cardiovascular

Answer 31

Edema
Increased heart rate
Orthostatic hypotension

Question 32

Physiological hazards of immobility: musculoskeletal

Answer 32

Decreased ROM
Joint contracture
Muscle atrophy

Question 33

Physiological hazards of immobility: elimination

Answer 33

Decrease urine output
Improper urine output (cloudy, etc)
Irregular BMs

Question 34

Physiological hazards of immobility: skin

Answer 34

Impaired skin integrity