Week 2: Health Assessment/General Survey/ADL's/Pain Flashcards
Definition: Activities of Daily Living
Basic tasks like eating, dressing, and moving around.
Definition: Acute Pain
Short-term pain and self-limiting, follows a predictable trajectory, and dissipates after an injury heals (after surgery, trauma, and kidney stones); acts as a self-protective purpose to warn of actual or potential tissue damage.
Definition: Chronic Pain
Persistent or recurring pain lasting longer than 3 months; can be categorized as malignant (cancer-related pain), nonmalignant (musculoskeletal conditions), or neuropathic (multiple sclerosis, poststroke syndromes, trigeminal neuralgia).
Definition: Continuous Pain
A form of chronic pain that lasts for weeks, months, or years; often impacting the muscles, bones, joints, and organs (arthritis).
Definition: Functional Health Assessment
Evaluates a person’s ability to perform daily tasks and participate in their environment; it can also help identify any limitations or areas for improvement.
Definition: General Survey
An assessment of a patient’s health that includes their appearance, mental status, mobility, and behavior.
Definition: Health History
The patient’s past health information including medical history, family health history, and other relevant details; used by healthcare providers to diagnose and treat patients.
Definition: Intermittent Pain
A form of pain that comes and goes rather than being constant; can occur for a number of reasons such as nerve damage, poor blood flow, ovarian cysts, etc.
Definition: Neuropathic Pain
A lesion or disease in the peripheral or central nervous systems causing abnormal processing of the stimuli (may be tingling, burning, ‘shooting’, numbness); (ex. MS, diabetic neuropathy, phantom limb syndrome, herpes, shingles).
Definition: Nociceptive Pain
Pain is experienced when there is tissue injury (fracture, cut to the skin) or inflammation (arthritis, colitis), and the pain sensing nerves (nociceptors) sense this event; may be described as aching, throbbing, sharp, dull, etc.; may be somatic or visceral.
Definition: Objective Data
Information that a nurse or other healthcare professional gathers about a patient through observation, measurement, or testing (temperature, BP, RR, HR, visible signs of an illness/disease, visible signs of discomfort/pain).
Definition: Pain Rating Scale
A tool that helps people measure their pain level, track any changes to pain levels, and aid in the development of a treatment plan; can be numerical 0-10 (Numeric Rating Scale NRS), by facial expression (Visual Analogue Scale (VAS), or by descriptor scale (no pain, mild pain, moderate pain, sever pain, very severe pain).
Definition: Referred Pain
Originates in one location but is experienced at another location; the same spinal nerve innervates both locations and it is difficult for the brain to differentiate the point of origin (EX. heart attack/MI).
Definition: Somatic Pain
Superficial (skin, subcutaneous tissue) or deep (bones, muscles, tendons, joints); typically localized and often described as aching or throbbing.
Definition: Subjective Data
Information provided by a patient to a nurse from the patient’s viewpoint or the viewpoint of a second party, such as a child’s parent. “I have a really sore head, I feel really tired”.
Definition: Visceral Pain
Larger interior organs such as intestines, gallbladder, pancreas (kidney stones, pancreatitis, appendicitis, ovarian cysts); pain may be constant or intermittent; pain may be caused by direct injury to the organ, or because the organ is stretched (tumors, cysts, stones, inflammation, distension).
What is a Health Assessment?
A collection of information about a person’s health
What is the purpose of a Health Assessment?
To gather a database about the patient so that we can make a judgement or a diagnosis about the person
What is Subjective information?
Subjective data is what the patient or their loved ones may say.
It is what the patient is feeling such as emotions, pain, throbbing, and other sensations.
What is Objective information?
Objective information is results from physical exams, lab and diagnostic results.
It is data that can be measured such as temperature, BP, RR, Pulse, SpO2 that can be reproduced by someone else.
What needs to be communicated to a patent at the beginning of a health assessment?
- Privacy
- Confidentiality
- Time
- Purpose
What sort of information is important for a Health History?
- Biographical data
- Reason for seeking care
- Current health or history of current illness
- Past health history
- Family health history
- Review of systems
- Functional assessment (including activities of daily living [ADLs])
What is Biographical Data?
Name
Address
Age
Gender/Pronouns
Culture
Religion/Spirituality
Language
Occupation
Martial status
Why is Culture important when taking Biographical Data?
It can help understand their:
Health beliefs
- Use of alternative therapies
- Nutritional habits
- Family and community relationships
- Level of comfort with physical closeness and examination
- Expectations of health and HC workers
- Gender preference for HC workers
Why is Religion/Spirituality important when taking Biographical Data?
Can impact how we can treat them.
Jehovahs & Blood; disease may be the punishment for sin.
What are Sources of Data?
- Client
- Family and significant others
- Health Care team
- Medical records
- Literature
- Physical exam
- Lab data
- Diagnostics
- Observation of client
What is a Sign?
- Objective abnormality.
- Can be observed, measured, felt, heard, or smelled.
- These can help to validate subjective thoughts
What are Symptoms?
- Subjective sensation or emotions.
- Nausea, throbbing, tingling (whatever the patient feels that CANNOT be measured).
What are factors to ask about when taking Current Health or Health History?
- Location
- Character/Quality
- Quantity/Severity
- Timing
- Setting
- Aggravating/Relieving factors
What is the acronym for a HEALTH assessment?
OPQRSTU
What does OPQRSTU stand for?
Onset
Provocative/Palliative
Quality/Quantity
Region/Radiation
Severity Scale
Timing
Understanding
What does OPQRSTUV stand for?
Onset/Origin
Provocative/Palliative
Quality/Quantity
Region/Radiation
Severity Scale
Timing
Understanding
Values/Views
What is the acronym for a PAIN assessment?
OPQRSTUV
What does O (Onset/Origin) mean?
When did it begin and where?
What does P (Provocative/Palliative) mean?
What makes it better?
Brings it on?
Etc.
What does Q (Quality/Quantity) mean?
How does it look? Feel? Sound?
What is its intensity/severity?
What does R (Region/Radiation) mean?
Where is it and where does it spread?
What is S (Severity Scale) mean?
On a scale from 1-10 rate the pain.
Does it change?
What does T (Timing) mean?
Timing, when did it start?
Does it ever stop?
What does U (Understanding) mean?
Understanding the patient’s perception
What does V (Values/Views) mean?
What is important? Other symptoms?
What do we want to know about Past Medical History?
Childhood illnesses
Serious illness
Accidents
Hospitalizations
Operations
Obstetrics
Chronic disorders
Immunizations
Last exams
Allergies
Medications
Why do we need to know about Family Health History?
We need to know if immediate family members have experienced:
- Heart dx
- Mental illnesses
- TB
- Obesity
- Cancer
And other issues that could be impact the patient’s health too
What does it mean to review the systems?
Review past and current health states of each body system, double check for omission of significant data.
What is a Functional Assessment?
It measures a person’s self-care abilities
What are some things evaluated in a Functional Assessment?
- Activities of Daily Living (ADLs)
- Instrumental Activities of Daily Living (IADLs)
- Organizing assessment around “functional health patterns”
What are Activities of Daily Living (ADLs)?
Activities such as bathing, dressing, toileting, eating, and walking
What are Instrumental Activities of Daily Living (IADLs)?
They are required for independent living such as housekeeping, shopping, cooking, laundry, and managing finances.
What is a Head to Toe?
A complete health assessment (health history and physical assessment).
** May not always be head to toe, may start with least painful/invasive to most.
What information should be asked during a health assessment on a CHILD?
- A prenatal and perinatal history.
- The parents’ description of the present problem.
- Any childhood illnesses or accidents.
- Immunization data.
- A developmental overview.
- A nutritional history.
What information should be asked during a health assessment on an ADOLESCENT?
- Home environment.
- Education and employment.
- Eating.
- Peer-related activities
Substance use (drug use). - Sexuality.
- Suicide or depression.
- Safety from injury and violence.
What should be considered during a health assessment on an OLDER ADULT?
- Consider how ADLs may be affected by normal aging processes or by the effects of chronic illnesses or disability.
- Note health strengths, social supports, and capabilities when able.
- Past health history – mostly focus on the last 5 years, unless they identify something prior to that relates to their reason for seeking care.
- **Family history less useful.
- Disease burden more important than actual diagnosis.
What is Pain?
Physical, sensory and emotional experience as the person has tissue damage, or possible/impending tissue damage
Is Pain a subjective or objective experience?
Subjective - it can only accurately be described by the person experiencing it
What is Acute Pain?
- Can often identify the cause of pain (Kidney stones, trauma, appendicitis, fractures).
- Typically lasts less than 6 months.
What is Chronic Pain?
- Not always an identifiable cause.
- Lasts longer than 6 months.
- May be persistent or intermittent.
- Triad of Therapies (Physical, Psychological, and Pharmacological).
What is the Triad of Therapies that follows the 3-P approach?
Physical
Psychological
Pharmacological
What is Nociceptive (physiological) Pain?
- It is the pain experienced when there is a tissue injury or inflammation and the pain sensing nerves sense this event.
How might Nociceptive (physiological) pain be described?
Could be described as aching, throbbing, sharp, dull, etc.
What are the two forms of Nociceptive (physiological) pain?
Somatic or Visceral
What is a Somatic source of nociceptive pain?
- Can be superficial or deep pain.
- Typically localized.
- Often described as “aching” or “throbbing”
What is a Visceral source of nociceptive pain?
- Occurs in larger interior organs (kidneys, pancreas, gallbladder).
- Felt during kidney stones, pancreatitis, appendicitis, ovarian cysts.
- Pain may be constant or intermittent.
- Pain also may be due to a direct injury to the organ or because the organ is stretched.
What is Neuropathic Pain?
- A lesion or disease in the Peripheral or Central Nervous System causing abnormal processing of the stimuli.
- May result in tingling, burning, shooting pain, or numbness.
(EX. MS, diabetic neuropathy, herpes, shingles).
What is Referred Pain?
- The injury/lesion is at one site but the pain is at another.
- Occurs when both sites are innervated by the same spinal nerve and the brain can’t determine the original site of injury.
(EX. MI/Heart Attack; pain is felt in the left arm).
What is the name of the pain that may occur when a patient’s level of pain is exacerbated temporarily despite having their intervention/treatment that typically controls the pain?
Breakthrough pain
What is Breakthrough Pain?
- Pain that breaks through the barrier of pain medication.
- May be predictable (movement) or unpredictable (spasm).
- May be idiopathic (unknown cause) or because the medication is wearing off.
What is the orderWhat is the order of the 4 specific processes that we experience in the body with nociceptive pain?
1) Transduction
2) Transmission
3) Perception
4) Modulation
What is Step 1: Transduction?
Nociceptors become activated when exposed to a noxious stimuli
What is Step 2: Transmission?
Stimuli are converted to electrical impulses that are relayed along peripheral nerves to the spinal cord and brain
What is Step 3: Perception?
Impulses carried by the fast pain A-fibers lead to the perception of sharp, stabbing localized pain. Impulses carried by the slow C fibers lead to the perception of a diffuse, dull, burning or aching pain
What is Step 4: Modulation?
Neurotransmitters that modify the sensation of pain, examples are serotonin, endorphins, enkaphalins, and dynorphins)
What sort of pain triggers flight-or-fight response in the (sympathetic/autonomic nervous system)?
Acute and Severe pain, superficial pain, or pain at a low to moderate level.
Will Acute and Severe pain, superficial pain, or pain at a low to moderate level trigger an Immediate or Long-term response?
Immediate Response
Will Prolonged, Deep, or pain involving large organs trigger an Immediate or Long-term response?
Long-term Response
What type of pain triggers the “rest and digest” response (parasympathetic nervous system)?
Prolonged, Deep, or pain involving large organs
What are some examples of sympathetic responses (flight-or-fight)?
- Increased HR
- Increased RR for O2 intake
- Increased blood glucose
- Increased muscle tension
- Pupil dilation
What are some examples of the parasympathetic response (“rest and digest”)?
- Rapid irregular breathing
- Weakness/exhaustion
- Decreased muscle tension
- Decreased BP and HR
What are some behavioural/emotional responses to pain?
- Facial expressions (grimace, frowning, clenching)
- Crying, screaming
- Bracing, rocking, guarding, tensing
- Fear, anxiety, anger
- Feelings of hopelessness
- Changes in eating or sleep patterns
What are some Contextual Factors when it comes to pain?
- Age (babies/children/older adults)
- Fatigue
- Attention
- Previous experience
- Family and social support
- Culture
- Cognition
Why do we assess Pain?
- Assessment is the basis for pain management
- Part of a complete physical and health history assessment
- To monitor, and manage pain symptoms (deciding on appropriate interventions, evaluating patient response to interventions)
- Reduce pain and suffering for patients
When do we assess Pain?
- Assessed with vital signs
- Re-assessed following intervention for pain to evaluate effectiveness
- Pre/post procedures
- When pain is reported, observed, or anticipated
What is the Numerical Rating Scale (NRS)?
A numerical scale where the patient ranks their pain from 0 to 10.
0 = NO pain, 10 = WORST pain
What is the Faces Pain Scale?
Often used with children so they can select the face that best represents their pain.
What are Validated Pain Assessment tools?
They are tools that must be used with patients who are unable to self-report pain.
What are some examples of patients unable to self-report pain?
- Neonates, infants
- Pre-verbal children
- People with intellectual disabilities
- Adults with confusion/dementia
- Critically il/unconscious patients
What are the 4 areas of assessment during a General Survey?
1) Physical Appearance
2) Body Structure
3) Mobility
4) Behaviour
What is Physical Appearance?
Includes age, sex, level of consciousness, skin colour, and facial features.
What is Body Structure?
Includes stature, nutrition, symmetry of body parts, and posture.
What is Mobility?
Includes observation of gait and range of motion.
What is Behaviour?
Includes facial expression, speech, mood and affect, dress, and personal hygiene.
What do ABCD’s stand for?
Airway
Breathing
Circulation
Disability
