W2: General Survey + Pain Assessment Flashcards
What is the general survey
Begins during your inital pt interaction, along with vitals, these are your intial observations. Collect data, making noes on PHSYICAL APPERACE BODY STRUCTURE MOBILITY, BEHAVIOR
- Physical Apperance
- Skin ( color, pigment, lesions etc) age ( appear like age developement) Facial Features ( symmetrical, dropin) Alterness ( able to answer) Sex, skin color, features
- During initial meeting take mental note of client apperance, note any signs of distress.
- Overall apperance/facialfeatures are the symmentrical. Any deformitiies, symmetry at rest and moving
- Age ( apperance consistent to age)
- Gender: certain conditions affect each
- Body Structure
Note any asymmetry, posture, body build, nutrition, stature
- Physcial and sexual development consistent with age ( posture, obese/lean, stature, symmetrical, build, joint abnormalities.
- Mobility
Gait ( well balanced stable walk), ROM, mobility of joins, ability to produce cooridnated movements.
- Behavior
Clear speech, calm tone, appropiate language , dress, personal hygine
–> Obsereve facial expressions whiel asking questions ( appropiate eye contact and any signs of anxiety or distress.
Affect: a person feelings as they appear on others , flat or blunted–> severe reduction in emotions could indicate depression Mood: appropriate
Speech: can they coney speech ideas, is it articulate
Level of Consciosuness
Do they respodn to their name, are they alert and oritented x 3 to place, person, time, event
- Verbal/motor commands followed
- Attentiveness and cognitive functions
- Ask questionns to assess their LOC
Hygine and Dress
- Clothing appropiate , footwear, clean, is hygine kept ( hair, odor, face)
Skin color, Hair, and Nails Assessment
- Skin: note the colouration and is it appropiate, cyanosis ( blue) or janduice , visble lesions or pigmentation. Is texture even and temperature , sweat?
- Hair: even, patches, color
- Nails: neat, cleaned
What is documentation?
Any written or generated that describes status of a client or the care given to client. Legal important document. Medical records allow for communciation between providers, contunity of care,
Guidelines for Documentation
Documentation cannot be done ahead of time and must be charting only your actions
- Fix documentation errors, during and afterwards
- Daymonthyear,
Components to documentation
Sequence: General Survey which is subjective data gathered from the OPQRSTUV pain assessment and objective data IPPA.
- Keep organized and accurate head to toe assessment or systemic approach
Documentation time different than assessment times
- Documentation should be clear considering timely chronological and organized
Document patient perspective and what we
see
Document your actions, correct errors
Leave pt in comfrotable position
CRNA practice standard: Knowledge based practice
“ RN documents timely, accurate reports of data collection
What to chart?
Initial and ongoing assessment
Current signs and symptoms
Interventions
Clients response to intervention
General survey data
What are the high risk documentation errors?
Falsifying records/documenting ahead of time
Failing to record client changes
Incomplete documentation
Failing to document notification of a primary provider
Methods of Documentation
Narrative Style: commonly used and involves story like format
Problem Oriented: Involves progressive style
Includes: SOAP ( subjective data, objective, assessment , plan)
SOAPIE (subjective, objective, assessment, plan, intervention, evaluation
PIE ( problem intervention and evaluation )
DAR: Data action response
Two approaches to documenting
- Charting by exception: focus on documenting unusual findings only. Often done on sheets, care maps that based on pre established guidelines.
- charting by inclusion: recording at least 2 per shift, head to toe assessment style.
Long term care charting
Individuals can be referred to-as resident rather than client. Their heath is often stable so documents can be done through flow sheets. Assessments done several times a day in acute, weekly in long ter.
- electronicrecord: connect care AHS enhancer communication.
Collaboration
Nurses must complete general survey, nurse directs NAP to measure, obtain vitals, report to nurse.
Developmental considerations
•older adults: changes in body posture gait, posture
Decreasing in weight and height
Vital signs: changes in body temperate irregular and shallow respiration breaths increased blood pressure. Pain isn’t part of normal aging process
Mild pain is 1-3
Moderate 4- 6
Severe 7-10
Pain assessment subjecting data
-pain is not a normal aging process
Subjective pt report: unpleasant sensory and emotional experience whatever is the pt experiencing
O-onset (when did the pain start, is it continuous)
P-provoking(what makes the pain better or worse)
Q-quality( what does the pain feel like is it a burning or pressure sensation what would you give it on a scale of 0-10)
R region ( where is the pain coming from and does it spread)
S-severe (scale and does it worsen)
T-timing (How long does it last ? changed over time , what has worked in the past other symptoms.
U- understand ( what do you think the issue is and any medications used)
V- value (how do you behave when in pain)
Nurses rule in pain assessment
To assess pain through objection data and subjective
Provide relief and assess noting reactions or adverse reactions
be an for advocate pain
teach how to manage
Pain assessment
Conducting an opqrstuv assessment
Gathering subjective data through the assessment and objective from vitals and IPPA
Acute pain behavior
Types of Pain
Acute pain: short term, self limits, follow predictable path after injury improves
Chronic: does not stop after injury, longer term, caused by unresolved acute pain, 3 signs of pain be missingmonths or more, can be cancer related or not,
Acute pain assessment
Severe pain not relieved by analgesics
Find cause and provide the relief
Prompt assessment and treatment reduces risks for disability
What two parts make up subjective assessment.
OPQRSTUV and pain tools
