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Nursing > 1180 Holistic Health Assessment ll > Flashcards

1180 Holistic Health Assessment ll Flashcards

1
Q

Why is the subject of PAIN important?

A
  • Pain is a universal symptom experienced by all at some point in their lives
  • Pain is the primary reason clients access health care in Canada
  • Pain can have a profound impact on a client’s function, quality of life, relationships, family structure, and financial resources, and mental health
  • Nurses are the health professionals that most often assess and help manage client’s pain
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2
Q

International Association for the Study of Pain (2012)

A

“An unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such.”

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3
Q

What is the pathway, or physiology of pain?

A
  • Nociceptors are PNS fibres and they carry painful stimuli to the CNS.
  • They are located in various body tissues
  • Activated by thermal, mechanical, and chemical stimuli.
    Impulse PNS
    |
    Spinal cord CNS
    |
    Pain may be blocked/ allowed to continue
    |
    Thalamus
    |
    The limbic system (emotions to control pain produced here)
    |
    Cerebral cortex (pain recognized here)
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4
Q

The 4 components of pain

A
  1. Sensory/ Physical
    - Action in pain nerves and effect on physiological status, severity- first thing patients usually feel. Nerves pick up on stimuli until stimulations are blocked by meds or something.
  2. Emotional/ Affective
    - How the pain makes us feel, fear, and knowledge.
    - Limbic system- emotions can make us feel things
  3. Cognitive
    - The effect of pain on behaviour, coping strategies, and what it means.
    - Gives pain meaning and what you think about it
  4. Social
    - Our behaviour, how we react and respond.
    - Influenced how other people react and we get cues from other people or I am getting a cue that we should stop talking about it.
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5
Q

Different ways to classify pain

A

DURATION
- Acute or Chronic

FREQUENCY
- Continuous or Intermittent

FORM
- Nociceptive or Neuropathic (nerve pain)
- Pain with no source ends up being neuropathic pain
- Neuropathic medication

ASSOCIATED WITH CANCER
- With cancer and / or with treatment for cancer.
-This actually gets its own class- bone pain is very bad
- Complex issue

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6
Q

What are the types of pain?

A
  • nociceptive and neuropathic pain
  • Visceral- organ pain. The lining of the abdomen and organs and the layers that cover organs will get infected
  • Somatic pain- felt pain
  • Cutaneous pain- superficial pain. Skin layers
  • Referred- pain felt in one part of the body and origin is somewhere else. Gallbladder problems but pain shows up in shoulder blade.
  • Parietal pain- the lining of the inside of the abdomen

NEUROPATHIC PAIN EXAMPLE: Phantom limb pain

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7
Q

What are the red flags for ACUTE pain assessment?

A

Acute pain is short in duration and should go away. I know where this is coming from, I know the origin, and I know it will go away.

Sudden onset is a red flag
; explosive headache- aneurism
; painful breathing
; chest pain
; abdominal pain
; severe pain unrelieved by appropriate medication- refractory pain is cause for concern

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8
Q

What to do in when assessing ACUTE PAIN?

A

New onset, indiscernible cause
what to do?
; focused/ emergent history
; involve others, family/ witnesses
; observation of the patient and their behaviours

The most reliable indicator of the existence of pain existence and its intensity is the CLIENT’S DESCRIPTION

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9
Q

The Patient’s Experience
WHAT FACTORS INFLUENCE PAIN?

A
  • age- more diseases, the immune system goes down with the combination of problems
  • gender- women’s pain overlooked- menstrual pain can be dismissive
  • culture
  • spiritual
  • family and social support
  • the personal meaning of the pain
  • levels of anxiety
  • coping style
  • fatigue
  • previous experience of pain
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10
Q

What is the Role of the Nurse?

A
  • the nurse is with the patient the most
  • in the best position to observe and notice/ monitor changes
  • one of the more important functions of the nurse is in the REASSESSMENT of pain- follow-up is key
  • the nurse is well positioned to document pain, responses to pain, assessments of pain, outcomes of various treatments, SUBJECTIVE data- other clinicians need this data
  • the nurse can make recommendations based on assessments- advocate for modifications of the treatment plan, communicate the client’s wishes, advocate for care, pain service
  • the nurse can explore complementary/ companion/para-medicine therapies with the client if interested
  • They ASSESS, TREAT, MONITOR
  • Document pain
  • Distract patient, bring ice, shift position
  • Treatments need to change
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11
Q

What are the effects of poorly managed pain?

A

Poorly managed pain results in increased circulating stress hormones which contributes to:

  • reduced cognitive/ mental function
  • the immune system gets down so if you have unmanaged pain you can get sick easily
  • sleeplessness, anxiety, fear
  • high blood pressure (hyperglycemia)
  • increased heart rate, increased cardiac output
  • decreased depth of respiration, decreased cough, sputum retention
  • muscle spasm, immobility
  • decreased gastric and bowel mobility
  • increased suffering for the client and loved ones
  • potential for the development of chronic pain

OVERALL DECREASE IN QUALITY OF LIFE

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12
Q

What are the ways to assess pain

A
  • OLDCARTSS
  • OPQRSTU
  • Numeric pain severity scale
  • Pain/ distress severity scale
  • Visual analogue scale- FACES
  • FLACC
  • Brief pain inventory
  • Universal pain assessment tool
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13
Q

What are the risk factors for Cardiovascular (Heart) Disease

A
  • Family history
  • Increased age
  • Elevated cholesterol
  • High blood pressure
  • High blood sugars levels or known diabetes Mellitus
  • Ethnicity
  • Obesity
  • Cigarette smoking
  • Sedentary lifestyle
  • Diet, sodium
    For females: menopause as risk for Coronary Artery Disease (CAD) increase thereafter
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14
Q

Signs and Symptoms of potential CV problem

A
  • Pain (chest, jaw, neck, left shoulder, left arm, sub-scapular, stomach pain)
  • Shortness of breathe
  • Dyspnea: difficulty breathing
  • Orthopnea: inability to breathe when laying flat
  • Paroxysmal nocturnal dyspnea: shortness of breath that wakes them up at night
  • cough
  • diaphoresis
  • Lightheadedness: not enough blood flow to the brain
  • Leg pain, ulcers to lower extermities: leg pain: often calf pain without much force being exerted on the muscle; arterial blood flow problem
  • nausea vomiting
  • edema: swelling, likely in the legs
  • fatigue
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15
Q

Assessment of CV system: History

A
  • Demographics/ SDoH
  • OLDCARTSS
  • Current/ recent symptoms
  • Associated symptoms
  • Inquire about respiratory concerns
  • Ask about risk factors
  • Discuss family history
  • Ask about past medical history, meds, allergies
  • Inquire about social history such as relationship
  • FUNCTIONAL ABILITY (ADL, IADL)
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16
Q

Physical Assessment:
VITAL SIGNS

A

start with vital signs

thing about the results, compare the results

interpret the results in the patient’s own context

How are the vital signs related- which ones are influencing others?

Do the findings require urgent action or monitoring?

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17
Q

Physical Assessment:
INSPECTION

A
  • general survey
  • skin color
  • respirations
  • speech pattern
  • diaphoresis
  • size, shape of thorax
  • fingers: nail-beds, clubbing
  • landmarks
  • abnormal pulsations
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18
Q

Physical Assessment:
PALPATION OF PULSES

A

Take note of the:
- rate
- rhythm
- strength/ volume: is it weak, thready, absent, normal, full, symmetry?

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19
Q

what pulse is considered objective data?

A

CAROTID PULSE ASSESSMENT

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20
Q

Auscultation: Unexpected Heart Sounds

A
  • Murmurs: turbulence causing “swooshing” or “blowing” sound
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21
Q

Landmarking
5 areas for listening to the heart

A

All People Enjoy Time Magazine
Aortic
Pulmonic
ERB’S point
Tricuspid
Mitral
S2 is best heard using diaphragm of stethoscope at pulmonary area

S1 is best heart at the apex using bell of stethoscope

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22
Q

S1 and S2

A

S1: loudest at the apex (bottom) AV valve closure (Mitral and tricuspid chambers) and beginning of systole

S2: loudest at base (top) SL valve closure (Aortic and pulmonic valve, out to body’ lungs)
beginning of diastole

23
Q

Effects of aging on the heart

A
  • the amount of collagen in the heart goes up and elastic goes down
  • decreased contractility and HR
  • cardiac valves become thicker and stiffer from lipid accumulation, valve incompetence or stenosis= murmur
  • # of pacemaker cells in SA node go down = heart block, bradycardia
  • decrease sympathetic nervous system control of cardiovascular system
  • arterial blood vessels thicken and become less elastic= increase BP
24
Q

When to perform a neurovascular assessment?

A
  • trauma/ injury to limb- soft tissue injury or a fracture or both
  • the presence of a cast or another protective device
  • surgery to a limb
  • the presence of a wound on a limb, varicose veins
  • conditions which may cause poor circulation- heart failure, diabetic peripheral neuropathy
  • client complaining of discomfort or pain limb
    other factors like smoking restrict circulation, hypothermia
25
Q

What is venous insufficiency

A

veins do not allow blood to flow back up to the heart

26
Q

what is varicose veins

A

veins that are overfilled with blood

27
Q

what is arterial insufficiency

A

slows or stops the flow of blood through arteries

28
Q

what is atherosclerosis

A

buildup of fats, cholesterol, and other substances in and on the artery walls

29
Q

Arterial vs Venous Insufficiency

A

arterial: pain with exertion- intermittent claudication
- relieved by short rest
- pale when leg elevated, rubor with dependency

venous: pain described as aching, dull, heaviness
- swelling as the day progresses
- pain and edema are relieved when legs elevated
- varicose veins

30
Q

Peripheral vascular assessment

A

Movement
Temperature
Sensation
Blanching
Colour
Edema
Pulse

31
Q

Reynauld’s

A
  • triggered by cold, stress
  • vasospasm
  • restricts blood supply to finger/ toes
  • turns white, feels numb
  • sometimes turns blue, then red before returning to normal
32
Q

Measuring arterial insufficiency
ANKLE- BRACHIAL INDEX

A

normal ABI
ankle- 120
brachial- 120. = 1.0

the lower the ankle pressure the greater the severity of occlusive disease and the higher the risk of cardiovascular events

33
Q

Compartment Syndrome = Emergency
5 Ps circulation assessment

A

Pain
Pulse
Pallor
Paresthesia
Paralysis

34
Q

Respiratory assessment
Do more people die because of pneumonia than because of the real reason they were in the hospital?

A

YES

35
Q

Ventilation, Diffusion, Perfusion

A

Ventilation: air going in and coming back out
Diffusion: gas exchange at capillaries
Perfusion: oxygenated blood’s ability to get to the tissues and deposit blood there.
when you press on nail bed the color should come back

36
Q

What do patients use for normal breathing vs not normal

A
  • breathing is normally effortless and it just happens.
  • when the patient starts using the throat, neck and shoulders to breathe it is NOT NORMAL.
37
Q

what are accessory muscles?

A

when the patient is using the throat and neck to breathe it is not normal and the patient is using accessory muscles.
- accessory muscles indicate distress

38
Q

Challenges to the respiratory system

A

Smoking
- killing our population
- first, second and third-hand smoking
- thirdhand smoking is smoke from someone- the odour of the smoke from someone or something else

Environmental factors
- home
- occupational - people who have to work in areas where they are exposed to triggers
- travel

39
Q

Subjective data- coming from the patient

A

ASK QUESTIONS SUCH AS:
- are you coughing? then ask characteristics
- are you coughing something out?
- if they cough something in front of you look at it, do not ask for the description then just look at it
- what colour is it?
- is there any blood?
- how much they are coughing up?
- odour (if there is odour then it is NOT a good sign)
- consistency (is it thing- not really concerning, thick secretion)

40
Q

Subjective data

A
  • cough?
  • Dyspnea? SOB SOBOE ( shortness of breathe) (shortness of breath on excretion)
  • Chest pain?
  • Past medical history
  • Family history?
  • Self care activities
  • Immunization
  • Allergies
  • Determinants of health
41
Q

Objective data
INSPECTION

A

Synopsis- deoxygenated hemoglobin, blue colour.
the person is not perfusing O2 in tissues
check for colour, odour, and ask for consent

42
Q

PALPATION

A

Excursion
- checking if both sides are exhaling and inhaling same time

Listen to clavicles
- Clavicles, midline then find space number 2 (slide fingers down to boney area then squishy area that is intercostal 2 and put stethoscope there.
at the back the landmark is C7 and measuring from there

43
Q

Landmarks for AUSCULTION

A
  • suprasternal notch- clavicle
  • the angle of Louis (sternal angle)
  • Costal angle
  • Scapular, clavicular, axillary lines
  • cervical vertebra #7
44
Q

what are the normal sounds of auscultating

A
  • bronchial
  • vesicular (most)
  • bronchovesicular
45
Q

what are the abnormal sounds

A
  • diminished sounds
  • absent sounds
  • friction rub
  • crackles- caused by fluid or mucus
  • wheezes
46
Q

What are the bronchial sounds

A
  • loud, hollow ‘tubular’ sounds
  • high pitched
  • considered abnormal if heard over peripheral lung fields
  • distinct pause between inspiration and expiration
  • inspiration to expiration ratio of 1:2 or 1:3
47
Q

what are the vesicular sounds

A
  • soft, low pitched
  • rustling quality with inspiration
  • even softer during expiration
  • majority of lung sounds
  • inspiration/ expiration ratio of 3:1
48
Q

Broncho- vesicular sounds

A
  • normally heard in the mid-chest
  • a mixture of high-pitch bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound
  • they have an inspiration to expiration of 1:1
49
Q

Adventitious sounds

A

Crackles
- fine crackles are brief, discontinuous, popping lung sounds that are high pitched

Friction rub
- low- pitched, short, grating sound from inflammation of the pleural surface

Wheezing
- musical sounds caused by narrowing airways - asthma

50
Q

promoting respirations and oxygenation

A
  • promote lung expansion
  • prevent stasis of secretions
  • maintain a patent airway
  • promote the adequate exchange of oxygen and carbon dioxide

alveoli- air sacks at the bases of lungs, and gases exchange.
want to keep them INFLATED. take the mucus and fluid out, promote lung expansion and keep them moving

51
Q

Developmental variations
INFANTS

A
  • they are obligatory nose breathers
  • belly breathers
  • babies breathing irregularly is normal
  • bronchovesicular sounds are heard
  • respirations are primarily abnormal
  • after the child is 2 the breathing is intercostal
    THE RESPIRATION RHYTHM IS IRREGULAR
    Apnea should NEVER exceed 15 seconds
52
Q

PREGNANCY

A
  • there is an increase in tidal volume to meet the fetus’s need for o2
  • later in the pregnancy the diaphragm rises and the costal angle widens to accommodate the enlarging uterus
53
Q

AGING
OLDER ADULTS

A

-Alveoli tend to fibrous with age resulting in decreased surface area for gas exchange
- lung capacity decreases due to muscle weakness and less elasticity
- there is more “dead” space, trapped air and less vital capacity
- often the thoracic spine curves (kyphosis) which gives the appearance of a barrel chest
- this does not usually result in dysfunction

Nursing (6 decks)

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