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Department
Nursing
Course
NSE 13A/B
Professor
Micheline Laforme
Semester
Fall

Description
HEALTH ASSESSMENT – 1 MIN QUIZ. CHAPTER 6 PAIN Definition: highly complex and subjective experience that originates from the CNS or peripheral N.S Referred Pain: pain that is felt at a particular site but originates from another location SOURCES OF PAIN 1) Nociceptive-pain due to tissue injury: • Somatic: superficial-derived from skin surface • Visceral: pain originates from larger interior organs ( kidney, stomach, intestines..) 2) Neuropathic: pain initiated or caused by a primary tension or dysfunction of the N.S ( can be severe and difficult to manage). ( ex: spinal cord injury) DEVELOPMENTAL CONSIDERATIONS INFANTS: under 2 yrs old tget can’t report pain & the location. Examiner should evaluate the changes in behaviour and watch for physiological cues. Kids 2+ can report pain and point to its location. RATING SCALES can be introduced at 4-5 yrs old. ADULTS: Pain is influenced by society expectations, hormones and genetic makeup. MEN-tend to be more stoic about pain while for WOMEN- pain is acceptable. AGING ADULTS: common in 65+ but it is not a normal process of aging. It indicates pathology or injury. PAIN ASSESSMENT QUESTIONS P : provocative ( cause, is it consistent?, what makes it better or worse?) Q: Quality/Quantity ( is it a burning pain? Sharp? Aching ?, Cramping?, itching?) R: Region: ( point where you feel the pain, is it only here or does it radiate?) S: Severity Scale ( how much pain do you have now?, at rest?, when you are moving?... using the scales to identify the degree ) T: Timing: ( when did it start?, is it steady?, constant?) U: understanding patient’s perception (how does it affect your daily activities?, does this pain limit your function or activities?, what does this pain mean to you?, why do you think you are having pain? PAIN SCALES: to reflect pain intensity, track changes, and give some degree of evaluation of treatment modality. 1) VISUAL ANALOG SCALE-indicates the intensity of pain the patient is feeling on a colored gradient and graduated line. 2) NUMERIC RATING SCALES: ask the patient to choose a number that rates the level of pain 0-being no pain and 10-indicating the worst pain. ( can be verbally or visually-vertical or horizontal line) 3) VERBAL SCALE: contain common words – No pain, mild, pain, moderate pain, and severe pain- to help describe the intensity or severity. – an alternative for older adults who have difficulty responding to numeric rating- 4) FACE SCALES: (THE WONG-BAKER) FACES: -facial expressions Ideal for children 5) BEHAVIOURAL SCALE: ( EX: PIPP: for premature infants) indicators of pain include gestational age, behavioural state before painful stumulus and change in heart rate, change in oxygen saturation, eye squeeze, temperament, expressions What personal individual factor influence the pain process: • Any traditional healers the patient may use • Gender- social expectations • Transcultural ( black and Hispanic feel less pain) • Pain may mean different to different people • Any fears about feeling pain CHAPTER 12 SKIN: Subjective questions 1) any previous skin disease or problem? And how was this treated? 2) Any allergies? Skin history of allergies? 3) Any birthmarks, tattoos? 4) Any change in skin color or pigmentation? 5) Any moles? Any change in mole..? size, shape, bleeding, itching? 6) Any change in the feel of your skin? Temperature, moisture or texture? 7) Any itching? 8) Any excess bruising? Where, how long.. 9) Any rash or lesions? 10) Any medications? 1) inspects and palpate the skin • observe skin tone Normal findings: • Consistent skin color, note for any freckles, moles, nevus, birthmarks • No color change 2) Temperature: note the temperature of your hands, then use the bacls of your hands to palpate the person. Normal findings: • Skin should be warm and temperature should be equal bilaterally ( warmth means normal circulatory status ) . • Hands and feet may be cold in cool environments 3) Moisture Perspiration ( sweating) normal on face, hands, axilla in warm environments and anxiety. 4) Texture Normal findings: smooth, firm, even surface 5) Edema: ( swelling )- to check: imprint your thumbs firmly against the ankle malleolus or the tibia. If your pressure leaves a dent in the skin then edema is present - It is not present normally. 6) Mobility and turgor to check: pinch up a large fold of skin on the anterior chest under the clavicle. Mobility= the skin’s ease of rising. Turgor: ability to return to place promptly when released ( represents the elasticity of the skin) 7) Vascularity or bruising: any bruising should be consistent with the expected trauma of life. And document if there are any tattoos. 7) Lesions: If lesions are present note: color, elevation (flat, raised), shape, size, location, LESIONS USING ABCDE MNEMONIC A: ASYMETRY ( when half of the mole does not match the other half) B: BORDER ALIGMENT (when the border (edges) of the mole are ragged or irregular) C: COLOR ( when the color of the mole varies throughout) D: DIAMETER ( No larger than 6 mm- size of a pencil eraser) E: ELEVATION AND ENLARGEMENT: ( flat, raised or pedunculated) 8) bony prominences THE BRADEN SCALE: 1) Sensory perception: 1-completely limited: unresponsive to painful stimuli,due to diminished level of consc
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