nurse 252 pain assessment Flashcards
(109 cards)
1
Q
what is a pain assessment?
A
an ongoing process
“fifth vital sign”
highly complex and subjective experience that originates from the CNS, the peripheral nervous system, or both
2
Q
how long should a nurse wait to reassess pain after administering drug therapy?
A
15-30 min after parental administration
30min to 1 hr after oral administration
3
Q
what is nociceptive pain?
A
caused by tissue injury
- well localized and described as aching or throbbing
- further classified as somatic or viscera
4
Q
what is somatic nociceptive pain
A
derived from skin, joints, tendons, muscles or bones
5
Q
what is visceral pain
A
pain that originates from the larger internal organs (eg, kidney)
6
Q
what is neuropathic pain
A
results from damage to the nerve pathway at any point along the nerve
-caused by direct nerve trauma, infectious disease (herpes hiv) or metabolic problems (diabetes)
7
Q
what is neuropathic pain described as?
A
burning, shooting, or lancinating, often intensifying at night
8
Q
can opiods work on neuropathic pain?
A
no
9
Q
do infants have the same capacity for pain as do adults?
A
yes, by 20 weeks the fetus can experience pain
10
Q
is pain a common experience for older adults that is normal?
A
pain due to “aging” is never normal
pain indicated disease or injury -never normal
11
Q
what is important to give pts in preparation for a painful experience
A
preemptive analgesia- administer it before repetitive painful procedure, eg dressing changes, suctioning
12
Q
what is sickle cell characterized by?
A
by alterations in hemoglobin and by anemia and tissue injury secondary to vaso-occlusion
13
Q
what will any decrease of oxygenation cause in a pt with sickle cell?
A
cause alterations in the shape of red blood cells, which causes them to stick together and ultimately block small vessels
14
Q
what does sickle cell cause?
A
severe pain in chest, long bones, joint pain or muscle pain
- usually in lower extremities
- common in afriacan decent / colored
15
Q
what is sickle cell crisis?
A
pain that suddnely appears and lasts for several days
-causes perihperal ulcerations, avasular (death of bone tissue) necrosis, and osteomyelitis (infection of bone)
16
Q
what is a sickle cell crisis caused by?
A
its brought on by psychological causes (stressful events) or physiological causes such as infectino or dehydration or stomach flu
17
Q
what do pts in a sickle cell crisis need?
A
-crazy amounts of pain meds, more than “enough”
18
Q
what ethnicities does sickle cell crisis happen in most?
A
african decent, mediterranean, caribbean, arabia, india, south and central america
19
Q
according to WHO, what mental disorders are the leading causes of disability?
A
Depression, alcohol use disorders, and psychoses
20
Q
what does cognition in a MSE involve assessing?
A
Consciousness, Orientation, attention, concentration, comprehension and abstract reasoning
21
Q
what is the MoCA?
A
takes 10-15 min
includes standerd sets of questions, ahs standardised administration methods -useful for initial and serial measurements so you can sue it to demostrate worsening or imporveing cognitino over a period of time w treatment
-considered a good screening tool to detect dementia and delerium to differnetiate these from psychiatric mental illness
22
Q
what do the scores on a moca indicate?
A
above 26 indicates no cognitive impariment
18-23 indicates mild cognitive impairment
0-7 indicates severe cognitive impairment
23
Q
what are the four cranial bones?
A
frontal, parietal, occipital and temporal
24
Q
what is the coronal suture?
A
what crowns the head ear to ear horizontalliy
25
what is the sagittal suture?
seperates the sides of the head lengthwise between the two partietal bones
26
how many facial bones are there?
14
27
what is the cranium supported by?
cervical vertebra: CI atlas and C2 axis
28
where are the parotid glands located?
in the cheeks over the mandible
29
what does a swollen parotid gland indicate?
possible mumps
30
where are the submandibular glands located?
beneath the mandible at the angle of the jaw
31
where are the siblingual glands located?
lie in the floor of the mouth
32
what is the thyriod gland?
an important endocrine gland with rich blood supply
33
where is the thyriod gland located?
it straddles the trachea in the middle of the neck - may be palpable is swelled
34
how is it possible to palpate the thyriod?
ask pt to swallow, will feel it come up
35
what does the thryoid gland do?
synthesises and secreted T4 and T3 hormones that stimulate the rate of cellular metabolism
-controls temp, growth, mood, metsrual cycles, body weight
36
if the thyriod is enlarged, what should a nurse auscultate for?
a bruit
37
what is a bruit?
a soft, pulsatile, shooshing sound best heard with the bell of a stethoscope
38
are bruits normal?
not normally present- indicative of hyperthyroidism
39
what is the job of lymph nodes?
to detect and eliminate foreign substances from the body
| -allows the flow of clear, watery fluid (lymph) from the tissue spaces into circulation
40
when lymph nodes are abnormal, where should u check for source of problem?
check the area in which they drain for the problem
41
what should a nurse do if lymph nodes are palpable?
note thier size, location, shape, mobility, consitency and tenderness (hard or fluid filled?)
- normal nodes should feel movable, discrete, soft and nontender
- concerning nodes are immobile (malignant) painful (infection) and hard
- always assume its malignant until its proven not
42
what is lymphadenopathy?
is enlargment of lymph nodes caused by infection, alergy, or neoplasm (cancer)
43
what does an enlarged lymph node, particularly when u cannot find the source of the problem, need?
needs prompt attention
44
what are come health history related questions to ask regarding the head, neck and lymph nodes?
Headaches?
Head injury?
Neck pain?
Lumps or swelling?
45
what important information should be gathered related to a pts headaches?
- onset (when did it start, gradual or over mins or hrs) (sudden can indicate brain hemmorhage)
-location: behind the eyes= migraine
-character: throbbing or aching (mild, moderate, or severe?)
-Duration: what time does it start? triggers? morning ot evening? how long do they last?
Precipitating factors? excercise, work, anxiety, alcohol?
Assocaited factors: nause or vomiting? and vision changes, pain with lights or neck pain, stiffness or fever?
46
what could neck pain associated with headaches mean?
menegitus
47
what important information should be gathered related to head injury?
-onset
-setting (were u wearing a helmet?)
- did you lose conciousness and then fall? or did you fall and lose consciousness?***
location (where exactly did you hit head)
duration: how long were you unconsious?
any symptoms after? headache, vomiting, projectile vomiting? dazed or sleepy?
48
what important information should be gathered related to neck pain?
onset- when did it start? car accident or with fever?
location? - does it radiate to the shoulders and arms?
associated symptoms: limited range of motion? does stress seem to trigger pain?
coping strategies: are you able to work or sleep?
49
where is the canthus located on the eye?
corner of the eye, the angle where the eyelids meet -at the inner canthus, the caruncle is a small fleshy mass containing sebaceous glands
50
what is the transparent protective covering of the eye called?
conjunctiva
| -a thin muscous membrane between the eyelids and eyeball
51
what provides constant irrigation to keep the conjunctiva and cornea moist and lubricated?
lacrimal apparatus
| -the lacrimal gland secretes tears (located under eyelid)
52
what is bells pasy?
when the eyes dont close all the way (need to put in eye drops at night)
53
what is the corneal reflex
a reflex from the sensitivity of the cornea, causing both eyes to blink
54
what does the iris do?
controls the amoung of light admitted to the retina
55
what is retinal detachment
describes as an emergancy situation in whicha thin layer os tissue (the retina) at the back of the eye pulls away from the layer of blood vessles that provides it with 02 and nutruents
- often accompanied by flahes and floates in vision
- eye can be saved if treated within 4 hrs
56
how often should u check a stoke pts eyes?
every 15 min
57
what is accommodation?
is the adaption of the eye for near vision
(skinny when far)
(close when near)
58
what is the acromyn for normal eye reponse?
```
P-pupils
E-equal
R-round
R-react to light
A- accommodation
```
59
what is presbyopia?
the lens loses elasticity, becoming hard and glasslike, which decreases the len's ability to change shape to accommodate for near vision- onset around 40 years old
60
where are "floaters" loacted in the eye?
vitreous humor
61
what should a nurse assess when a pts visual acuity delcines?
risk for falls
62
what is glaucoma?
increased intraocular prssure
- involves gradual loss of peripheral vision
- leading cause of irreversible blindness in world
63
what causes cataracts?
results from clumping of proteins of the lens
- secondary to diabeties
- 50% if ppl ages 70-79 have cataracts (can be surgically removed)
64
what is macular degeneration
the breakdown of cells in the macula of the retina
- loss of central vision, the area of clearest vision
- is the most common cause of blindness
65
what is diabetic retinopathy?
- remains the leading cause of vissual impairment of ppl younger than 65
- pts who are diabetic should be refered to a eye docotr every 2-3 years for screeming of this
66
questions to ask to pts for eye assessment?
- did visual change come on suddenly ot develop slowly? - in one eye or both?
- is it constant?
- Do spots move in front of your eyes?
- Any halos?
- Any blind spots?
- Any loss of peripheral vision?
- eye pain? burning or itching?
- History of cross eyes? does this occur with eye fatigue?
- Diplopia?
- redness, swetting? any infections
- Discharge? excessive tearing? is there discharge in the morning?
- use of glasses or contacts? do they work for you? when was last perscprition checked?
67
in what situation are floaters common?
With mypoia (nearsightedness) or after middle age, but acute onset of floates can indicate retinal detachment
68
halos around lights occur with acute what?
acute angle glaucoma
69
what is ptosis? (tosis)
drooping upper eyelid
70
what is ectropion? (ec-trop-ion)
drooping lower lid (seen with old ppl)
71
what is hordeolum (stye)
is a localized infection or inflammation of the eyelid margin involving hair follicles of the eyelashes (ie, external hordeolum) or meibomian glands (ie, internal hordeolum). A hordeolum usually is painful, erythematous, and localized. It may produce edema of the entire lid.
72
what is iritis
inflammation of iris
73
what is subconjunctival hemorrhage
bleeding under conjunctiva (common with ppl who have been assulted)
74
What is hyphema?
is a pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris).
75
what is the ear canal lined with?
glands that secrete cerumen (ser-u-men) (ear wax) that helps keep foreign bodies from entering and reaching the sensitive eardrum
76
what seperates the external ear from the middle ear?
tympanic membrane
77
what is conductive hearing loss?
involves a mechanical dysfunction of the external ear (eg, may be caused by impacted cerumen, foreign bodies, or perforated eardrum
78
what is sensorineural hearing loss?
signifies disease of the inner ear, occurs with aging
79
what will happen if teh labyhrinth becomes inflamed?
it will feed thr wrong info to the brain, causing the prson to have a staggering gait and a strong spinning sensation called vertigo
-person will be stumbling, vomiting, feeling like the room is spinning
80
what is the romberg test?
a test where a pt stands still in one place - determines ability of the vestibular apparatis in the inner ear to help maintain standing balance
81
what is Otitis media
-middle ear infection
-results from obstruction of the eustachian tube or of passage of nasupharyngeal secretions into the middle ear
-most common illnesses in children
-increased incidence of otitis media when feeding infant in supine position- milk and food can travel up eustachian tube and creates an infection.
enourage parents to hold baby partly upright against arm while feeding
82
what is some important information to ask pt about ears?
-presence of earache- any pain in ears? does it hurt when push on ear? any accompanying cold or core throat symptoms?
Infections: any ear infections in adulthood or childhood?
-discharge: any discharge from your ears? does it look bloody?
-Hearing loss: ever had trouble hearing? has all your hearing decreased, or just hearing a certain sounds?
environmental noise: any loud noises at home or job?
83
what is important to keep in mind about the relationship between upper respiratory tract infections and middle ear infections?
A virus that causes upper respiratory tract infections may migrate up the eustachian tube to involve the middle ear
84
for an adult, what direction do u pull on ear to assess it?
pull pinna up and back
85
for a child under 3, what direction do u pull ear to assess it?
pull pinna straight down
86
what is exostosis?
the formation of a new bone in ear
87
what is polyp
otic polyp (also called aural polyp) is a benign proliferation of chronic inflammatory cells associated with granulation tissue, in response to a longstanding inflammatory process of the middle ear
88
what is perforation
damage from 1 tips, or can happen from presuure when scuba diving
89
where does the nasal cavity extend to?
extends back over roof of mouth, lined with clilated mucous membrane
90
what do nasal hairs filter out?
coarsest matter from inhaled air
91
what does the mucous blanket filter out?
dust and bacteria
92
what are the paranasal sinuses?
air filled pockets within the cranium- serve as resonators for sound production and provide mucus
93
which pairs os sinuses are accessible to examination?
frontal and maxillary (above eyebrows and on upper cheeks)
94
which sinuses are deep within the skull?
Ethmpod and sphenoid (cant be palpated)
95
how mant teeth do adults have
32, woooww
96
what is some subjective data to ask for nose assessment?
discharge: it is continous? watery? purulent or bloody?
frequent colds: how often do the occur?
sinus pain: how is it treated? do u have chronic post nasal drip?
trauma: ever had a blow to the nose> is either side obstructed?
epistaxis: (nose bleeds) how ofte, how long, from one nostril or both?
allergies? any hay fever?
97
what is some subjective data to gather about mouth and throat?
sores or lesions: in mouth, tongue or gums
sore throat: is it associated with cough, fever, or fatigue?
bleeding gums: how long have you had this?
toothache: sensitve to hot or cold?
dysphagia: any difficutly swallowing? do u feel like food is stpped at a certain point?
altered taste: any changes in sense of taste?
smoking: pipe, cig, or smoke less tobacco?
self care: tell me about your daily dental care? lest dental exam?
98
what do normal tonsils look like?
same color as the surrounding mucous membrane, althoug they look more granular, and deep crypts are visible on thier surface
99
how are tonsils graded?
1+ (visible
2+ (halfway between tonsillar pillars and uvula)
3+ touching ivula
4+ touching eachother
100
what do tonisils look like with infection?
with acute infection, tonsils are bright red, swollen, and may have exudates or large white spots
101
what is epistaxis (ep-i-stax-is)
nose bleed
102
what is perforated septum
is a medical condition in which the nasal septum, the cartilaginous membrane dividing the nostrils, develops a hole or fissure.
cocaine can burn hole
103
what is sinusitis
inflammation of the sinus
104
what is cleft lip
a congenital split in the upper lip on one or both sides of the center, often associated with a cleft palate.- birth defect
105
what is baby bottle tooth decay
Baby bottle tooth decay happens when sweetened liquids or those with natural sugars (like milk, formula, and fruit juice) cling to an infant's teeth for a long time.
106
what is gingivitus
means inflammation of the gums, or gingiva. It commonly occurs because a film of plaque, or bacteria, accumulates on the teeth. Gingivitis is a non-destructive type of periodontal disease, but untreated gingivitis can progress to periodontitis
107
what are dental caries
Tooth decay, also known as dental caries or cavities, is a breakdown of teeth due to acids made by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating.
108
what is black hairy tongue
caused from medication, ex, peptobysmol
109
what is phartngitis
Pharyngitis is caused by swelling in the back of the throat (pharynx) between the tonsils and the voice box (larynx). Most sore throats are caused by colds, the flu, coxsackie virus or mono (mononucleosis). Bacteria that can cause pharyngitis in some cases: Strep throat is caused by group A streptococcus
