Quiz #1 Flashcards
What is the purpose of a nursing assessment? Identify from your readings five reasons to complete an assessment.
- Emotional, intellectual, physical, psychosocial, spiritual, cultural components of evaluation
- Address patient need (chief complaint, yearly physical screening..)
- Health history, current status, nursing diagnosis, clinical judgements, expected outcomes, evaluation.
- Gather data -> develop -> create care plan -> manage patient concerns -> evaluate nursing care
- Confirm + identify diagnosis (DX); make judgements/decisions care -> EVALUATION - Applying social and cultural considerations (boils trust, connection, respect)
Added notes:
- Baseline Data; supplement, confirm or repute a previous finding.
Settings: Environment includes:
- Privacy (curtain)
- Comfort (lighting,
- Proper equipment
- Proper positioning
- Proper organization/sequence of exam
- Physiological + physical safety
- Proper infection control.
What do the terms “acute” and “stable” refer to? How do these concepts relate to the frequency and type of assessments nurses complete?
Acute: dynamic health problem, acutely ill patient that requires intervention
1. Primary assessment:
- Done in ED
- General survey, focused assessment
- Can be every couple hours, completed every shift (primary assessment head-to-toe)
Stable: A patient who’s health status is stable and consistent. Health status is not acute
- Something unusual? -> focus assessment
- Annual physical exam, screening assessment + primary care exam.
- Can be done annually or can be screening assessment + can be completed at primary care visit.
Describe primary, secondary, and tertiary sources of health assessment data.
Primary: their description of the presenting problem, medical history and narratives of health experiences.
Secondary: nursing notes/charting, physician progressive notes and medical administration record. It’s important to acknowledge that clients are dynamic and chart data records allows history but dosent always reflect current health status.
Tertiary: it provides information to client frame of reference such as relevant literature and nursing experience.
- Understanding commonalities among clients with similar physical and emotional response.
Identify three relational practice and communication principles to use when conducting assessments.
- A thorough examination of purpose and steps of each assignment
- let client prepare and lets them know what to expect - Allow/help client feel confident to ask question sand to mention discomfort
- Convey an open professional approach while remaining calm and relaxed.
- still demeanour will inhibit reaction + too cause will fail to assure the client.
Identify four ways to keep your patient safe and physically comfortable during an assessment.
- Ask for consent and check in to make sure client is comfortable
- Use relational practice skill like “SOLAR” to make your patient feel heard
- Describe the procedure to your patient to make them feel included
- Try to keep their equipment warm and make sure they are comfortable
Identify three ways you will attend to infection control practices when assessing a patient.
- Proper hand hygiene
- Proper disposal of soiled material
3.using PPE when necessary
Identify eight principles and/or organizational tips nurses apply when completing assessments.
- Compare both sides of body for symmetry
- If they are seriously ill assess the systems more at risk for being abnormal
- if the patient gets fatigued offer rest periods
- Preform painful procedures at the end
- Record assessments in specific terms on a physical assessment form/nurses notes
- Use common and accepted medical terms to keep things short
- Use quick notes during assessment and compete them after
- The physical assessment forms allow the info to be written in the same order it’s was gathered.
Identify and describe five particular techniques nurses use during assessments.
- Inspection – use vision and hearing to distinguish normal vs. Abnormal findings
- Palpation – using hands to touch body parts in order to make sensitive assessments
- Percussion – tapping body with fingers to produce vibration through body tissue
- Auscultation – listening to sounds of the body to detect variations of normal
- Olfaction – smell can distinguish normal vs abnormal body orders
- body, urine, wounds breath, etc.
Differentiate between subjective and objective data.
Subjective: what the patient is telling you, saying they feel pain, not having an answer for what’s going on.
Objective: things you can observe, is confirmed from results and matches patinet’s symptoms, from test results/vita.
Differentiate between physical and screening assessments.
Physical: hands on assessment with patient
Screening: mammogram, BSE, prostrate exam, stool/bowel Ca
List three or four additional assessments a nurse includes in a holistic assessment (i.e., cultural assessment).
- Cultural
- Family
- Psychosocial (mental)
Differentiate between and summarize the main types of health assessments used by nurses.
- Primary survey:
- structural assessment helps nurse recognize and act on signs of clinical detoriation
- airway, breathing, circulation, disability, exposure
- collects data in order of importance
- rapid response system - General survey
- information about characteristics of an illness, pt. Hygiene, emotional state, recent changes in weight, and developmental status - Focused assessment
- survey/assessment about a specific body system/health concern
- related to specific signs or symptoms that are presenting - Head-to-toe (10 min)
- assesses several body systems
- Provides overview of pt. Health
- Collected data can influence the need for further examination - Complete health assessment (45-60 min)
- simulator to head to toe
- more comprehensive
- includes objective and subjective assessment of all body systems.
Compare and contrast the Nursing Process (ADPIE) with Tanner’s (2006) Thinking Like a Nurse model.
ADPIE:
- Implementation
- Linear
- More patient friendly when explaining cure
- STABLE beginnings
Tanner:
- More complex and more in depth
- More specific reflection
- Acute + advanced
Similarities:
- Follow same rubric
Assess = noticing
Dx/Plan = interpreting
Intervention = responding
Evaluation = reflection
When is a complete health history is utilized by the health care team?
- When patients are admitted to the unit (within the 4 hours!)
- It is a “form” that is 2pgs that prompts the procedures needed, organized, least invasive -> more invasive (trauma informed care)
How is this useful for the nurse/health care team for the care of the well patient?
Baseline: It is used to assess overall health status, health maintenance goals, and health-promoting practices, such as exercise pattern, diet, risk and harm reduction, and preventive behaviours such as immunization status, age-appropriate health screening, limiting screen and sedentary time, or helmet use during sports activities.
How is this useful for the nurse/health care team for the care of the ill patient?
- It includes a detailed and chronological record of the health problem.
What are the systems you will assess as part of this health history review of systems?
- Biographical data: the patient’s name, age and birthdate, birthplace, other recent countries of residence, sex, gender, relationship status, and usual and current occupation or daily activity pattern (an illness or disability may have prompted a change in occupation or usual patterns of activity). And sometimes preferred language.
- Reason for seeking care: a brief, spontaneous statement in the patient’s own words that describes the reason for the visit.
- Current health or history of current illness:
Healthy patient: a short statement about the general state of health.
Ill Patient: a chronological record of the reason for seeking care, from the time the symptom first started until now. Isolate each reason for care identified by the patient. - Past health history: Past health events may have residual effects on the current health state. Also, patients’ previous experience with illness may give clues as to how they respond to illness and to the significance of illness for them. Ex. Childhood illness, accidents or injuries, serious or chronic illness, hospitalizations, operations, immunizations, allergies, and current medications.
- Family health history: the ages and health, or the ages at and cause of death, of blood relatives, such as parents or other primary caregivers, grandparents, and siblings.
- Review of systems: The order of the examination of body systems is approximately head to toe.
(a) to evaluate the past and current health state of each body system,
(b) to double-check in case any significant data were omitted in the Current Illness section, and
(c) to evaluate health promotion practices. - Functional assessment (including activities of daily living [ADLs]): you measure a patient’s self-care ability in the areas of general physical health or absence of illness; activities of daily living (ADLs), such as bathing, dressing, toileting, eating, and walking; instrumental activities of daily living (IADLs), which are activities needed for independent living, such as housekeeping, shopping, cooking, doing laundry, using the telephone, and managing finances; nutrition; social relationships and resources; self-concept and coping; and home environment.
- self concept
- sleep and rest
- nutrition and elimination
-Interpersonal relationships
-Spiritual resources
-Coping and stress management
-Tobacco use history
-Alcohol
-Substance use
-Environmental hazards
-Intimate parter violence
-Occupational health
describe the difference between a sign and a symptom and give one example for each.
Symptom: what the patient is feeling but we are not able to see or measure (subjective) eg. Stomach ache or pain from 1-10
Sign: a measurable or visible outcome of a health abnormality that health care workers can detect (objective) ex. Increased heart rate or a broken bone
- Identify two or three things to consider when assessing pain in older persons.
- Pain is not a natural occurrence of aging, although there are risks of experiencing more pain
- Take time when planning pain assessment (patient-centred care)
- Fear of becoming “addicted”
- Fall risk/sedation
1) Older persons who are able to express themselves can use self-report pain scales. In addition, assessment should include how the pain is affecting function, sleep, appetite, activity, mood, and relationships with others (Booker & Haedtke, 2016).
Practise person-centred care and take the time required when explaining a pain-assessment scale.
2) Pain is not a natural occurrence of aging, although older persons are at risk for experiencing more pain-producing conditions.
3) Nonverbal older persons experiencing pain are at high risk of inadequate analgesia (Allione, Pivetta, Pizzolato, et al., 2017). Ensure that your assessment is thorough and evaluate a patient’s response critically.
- Identify two or three things to consider when assessing pain in children.
- Children w/ verbal skills an rate their pain on their face scale and numeric 0-10 used @ age 7
- FLACC
- May have misconceptions about the cause of pain or fear of consequences ex. Needle
- Culture
1) Some children are reluctant to report pain because they have misconceptions about the cause of their pain or they fear the consequences (e.g., another painful procedure or an injection).
2) Infants and children experience pain but respond to it differently than adults. Infants and children who do not have the ability to self-report their pain are at risk of having their pain go unrecognized. A valid observational pain assessment tool such as the Face Legs Activity Cry Consolability–revised (FLACC-r), the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS), or the COMORT/COMFORT scale (Andersen, Langius-Eklof, Nakstad, et al., 2017) should be used.
3) Parents are helpful when assessing their child’s pain and planning pain-relief therapies. Most parents know how their child exhibits pain and which pain-relief interventions have been successful.
4) Children with verbal skills can rate their level of pain on the FACES Scale, FACES Pain Scale– Revised, pain rating scale, or Numeric Rating Scale (0–10). The Numeric Rating Scale (0–10) can be used in children over the age of 7 years. With children, 0 = no pain. However, there is no consensus on what 10 should mean. “Most hurt” or “worst hurt you can imagine” are suggestions for defining “10” (Castarlenas, Jensen, von Baeyer, et al., 2017). The absolute value of a pain-intensity score is not as important as the changes in scores in each individual child. In clinical use with children, a change in pain of 2 of 10 (i.e., a change of one face) represents the least change that can be considered clinically significant when using a FACES Scale–Revised (Tsze, Hirschfeld, von Baeyer, et al., 2015).
5) • Pharmacological pain support is safe and effective in pediatric patients when the dose is calibrated according to the child’s weight; however, recent evidence cautions that this practice may be inappropriate for obese children (Vaughns, 2017).
2) Why are infants, children and older persons at risk for under-treating pain?
- Some ages and conditions common in infants, children and older persons inhibit them from describing or express themselves and their symptoms.
- Verbal communication, unable to self-report
- Dependency
- Infant: patents advocate
- Children: self/parents advocate
- Older adults: self/caregiver (LOC -rushed assessment)
3) Name two tools used to quickly assess pain across the lifespan (besides the 0-10 Pain Scale).
1) For patients with dementia or those who have no verbal skills, use observational pain assessment scales such as the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC-II) and the Pain Assessment in Advanced Dementia scale (PAINAD)
- Assess physical, behavioural, and emotional signs and symptoms of pain:
a. Moaning, crying, whimpering, groaning, vocalizations b. Decreased activity
c. Facial expressions (e.g., grimace, clenched teeth)
d. Change in usual behaviour (e.g., less active, irritable) e. Abnormal gait (e.g., shuffling) and posture (e.g., bent,
leaning)
f. Guarding a body part
g. Diaphoresis
h. Changes in sleep patterns
- FACEs pain scale/visual analogue scale (gives a picture and simple description – children)
- Descriptor scale (describes pain – older adults)
- OPQRSTV pain mnemonic (guidelines for questions)
2) Assess characteristics of pain. Follow employer policy regarding frequency of assessment. Use the OPQRSTUV pain assessment.
a. Compare and contrast acute pain and chronic pain. What do you imagine are the differing signs and symptoms of these two experiences?
Acute: a response to and experience of unpleasant stimuli. It motivates lasts from hours to days or a month after the precipitating event. It resolves as tissue healing occurs behaviours to avoid potential or actual tissue damage. It is recent in onset and is self-limiting,
Chronic: Chronic pain is defined as pain that lasts longer than 3 months or past the time of normal tissue healing. It can impact the person’s physical, psychological, and social well-being.
b. What effect does acute and/or chronic pain have on quality of life and ADL’s/iADL’s?
- Adequate pain relief allows patient to participate in activities of daily living (ADLs).
- Pain can prevent people from assessing ADL/iADL
c. Compare and contrast an “initial pain assessment” to a “brief pain inventory”. Which assessment guide/tool is most appropriate for acute pain? Why or why not?
initial pain assessment:
O: onset - When did the pain start?
- To identify onset of pain (when active, or resting) or whether pain is acute/chronic.
P: provocative/palliative - Does your pain increase with movement or activity? Are the symptoms relieved with rest? Were any previous treatments effective?
- To identify quality of pain and differentiate between nociceptive and neuropathic pain mechanisms.
- To identify alleviating and aggravating factors.
- To evaluate effectiveness of current treatment.
Q: quality of the pain - What does your pain feel like? What words describe your pain?
- To identify mechanism of pain (terms such as “throbbing,” “aching,” “shooting,” and “dull” may provide clues).
R: region of the body/radiation - Where is your pain? Does the pain radiate, or move to other areas?
- To identify one or more areas of the body that are affected by pain, inasmuch as there may be several.
S: severity of pain -How would you rate your pain on an intensity scale?
- To identify intensity (refer to various intensity scales).
- To identify degree of impairment and effect on quality of life or ability to perform activities of daily living (ADLs).
T: treatment/timing - What treatments have worked for you in the past? Is it a constant, dull, or intermittent pain?
- To identify treatments which have been successful in the past.
- To identify the timing of the pain so that treatment can be focused on spikes in pain.
U: Understanding of pain - What do you believe is
- causing the pain?
- To understand patient history of pain.
- To be able to set achievable pain and function goals when reviewing the plan of care.
V: values - What is your acceptable level for this pain? Is there anything elsethat you would like to say about your pain? Are there any other symptoms related to the pain?
- To understand and discuss other stressors, spiritual pain.
Brief pain inventory: The patient rates the pain within the previous 24 hours, using graduated scales (0 to 10); indicates how much relief the patient has had; and describes how the pain interferes with areas such as general activities, mood, walking ability, work, and sleep
a. What is the relationship between anxiety/ fear and pain?
People are fearful of mowing they will experience pain and therefore become anxious.
Chronic pain can result in fear and anxiety of ADLs + iADLs
b. When assessing a person in pain, why does a nurse take a health/illness history and a history of the type of medications/therapies they have tried?
To see if they are taking any medications or have any health conditions or incidents that might be related to the pain.
To know what hasn’t/isn’t working in relation to therapies and medications.
7) Identify two or three person-centred principles to follow when assessing pain.
- Patient advocacy
- Patient empowerment
- Compassion + respect
8) What is nociceptive pain and what are the words used to describe this sort of pain.
Nociceptive pain: caused by tissue injury or damage. It is well-localized and often described as aching, sharp or throbbing.
Nociceptive pain can be further classified as somatic or visceral.
Somatic pain can be superficial (superficial somatic or cutaneous pain), derived from skin surface and subcutaneous tissues, or deep (deep somatic pain), derived from joints, tendons, muscles, or bone. Visceral pain originates from the larger interior organs (e.g., kidney, intestine, gallbladder, and pancreas). The pain can stem from direct injury to the organ or from stretching of the organ as a result of tumour, ischemia, distension, or severe contraction.
9) What is neuropathic pain and what are the words used to describe this sort of pain.
Neuropathic pain: caused directly by a lesion or a disease affecting the somatosensory nervous system. Sensation of pinpricks, cold, loss of sensation
Neuropathic pain can result from damage to the nerve pathway at any point along the nerve, from the terminals of the peripheral nociceptors to the cortical neurons in the brain. Examples of neuropathic pain may include pain caused by direct nerve trauma (spinal cord injury), infectious diseases (herpes zoster, human immunodeficiency virus [HIV] infection), or metabolic problems (diabetes), or it may be medication-induced (chemotherapy, antiretroviral therapy).
10) What other words are used to describe pain?
• Aching.
• Throbbing.
• Cramping.
• Gnawing.
• Heavy.
• Hot or burning.
• Sharp.
• Shooting.
• Stabbing
• Ripping
• Grinding
• Poisoned
- Observed, noticed, inspected
- Palpated…
- Odour noticed
- ANS calculated
11) Identify objective assessment findings a nurse might observe, inspect, or palpate associated with pain? (What does it look like when someone is in pain? Does a person in acute pain look the same as a person in chronic pain?)
Assess physical, behavioural, and emotional signs and symptoms of pain:
a. Moaning, crying, whimpering, groaning, vocalizations b. Decreased activity
c. Facial expressions (e.g., grimace, clenched teeth)
d. Change in usual behaviour (e.g., less active, irritable) e. Abnormal gait (e.g., shuffling) and posture (e.g., bent,
leaning)
f. Guarding a body part
g. Diaphoresis
h. Changes in sleep patterns
12) Identify primary, secondary, and tertiary sources of data when assessing pain?
Primary: collecting data from patient
Secondary: data found in chart, diagnostic imaging + test, lab reports
Tertiary: data from literature (medical + pharmacological) that relates to patient’s condition (Our experiences)
Pharmacologic?
a. Pharmacologic – relating to the branch of editing concerned with the uses, effects and modes of action of drug
b. Analgesic?
– the action of a drug relieving pain
c. Multimodal analgesia?
– several different modes of activity or occurrence + the action of a drug relieving pain
Adjuvants or coanalgesics?
- A substance that enhances the body’s immune response to an antigen/ a group of pharmaceuticals with pharmacological characteristics that were not primarily intended for pain relief but were found to have therapeutic properties when used independently or in conjunction with opioids.
e. Non-pharmacologic
- the management of pain without medications.
