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Nursing 1180 Midterm > Week 1-4 > Flashcards

Week 1-4 Flashcards

1
Q

Why is Pain Assessment Important?

A
  • Universal symptom experienced by everyone at a certain point in their lives
  • Pain is primary reason clients access healthcare in Canada
  • It has a profound impact on the client’s function, quality of life, relations, family structure, and financial resources
  • Nurses most often assess and help manage a client’s pain
  • everyone experiences at a different extent and some live with chronic diseases that come with pain or acute injuries
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2
Q

What does the International Association for the Study of Pain state?

A

” an unpleasant emotional and sensory experience associated with actual and potential tissue damage, or describes in terms of such”

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3
Q

4 Components of Pain

A
  1. Sensory/Physical
    - action of the pain nerves and effect on physiological status, severity ; stimuli continues until medications stops it
  2. Emotional
    - how the pain makes the client feel, fear, knowledge;
  3. Cognitive
    - effect on behaviour, coping strategies, what does it mean
  4. Social
    - behaviour influenced by cues from others and their reactions, how do you react and respond
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4
Q

Different ways to classify pain

A
  1. Duration
    - acute vs. chronic
  2. Frequency
    - continuous or intermittent (come and go)
  3. Form
    - nociceptive(damage to tissues) vs. neuropathic(nerve pain)
  4. Associated with Cancer
    - pain due to cancer or treatment of cancer
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5
Q

Types of Pain

A
  1. Nociceptive vs. Neuropathic
  2. Visceral
    - organ pain
  3. Somatic
    - felt pain
  4. Cutaneous
    - superficial, skin layers
  5. Referred
    - pain is happening but the origin is somewhere else
  6. Parietal
    - inflammation of abdomen lining
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6
Q

Acute Pain Assessment

A

Sudden onset is a red flag
- explosive headache, chest pain, painful breathing, abdominal pain, pain that is not being relieved by medications

What to do
- take a focused/emergent history
- involve others, family/witnesses
- observe patient and their behaviour

Most reliable indicator of the existence of pain and its intensity os the client’s description of it

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7
Q

The Patient’s Experience: Factors Influencing their Pain

A

age
gender
cultural
spiritual
family and social support
personal meaning of pain
level of anxiety
fatigue
coping style
previous experiences of pain

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8
Q

Role of Nurse - Pain

A
  • The nurse’s are with the patient the most
  • In the best position to observe and notice/monitor changes
  • Important function is the reassessment of pain, follow up is key
  • Document pain, responses to pain, assessments, and outcomes of various treatments
  • Make recommendations - advocate for modifications in treatment plan, communicate client’s wishes and consultations with other services
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9
Q

Effects of Poorly Managed Pain

A

Overall decrease in Quality of Life
- reduced cognitive/mental function
- anxiety, sleeplessness
- High blood sugar
- Increase HR, cardiac output
- Decreased depth of respirations, cough, sputum retention
- Decreased immune response
- Muscle spasm, immobility
- decreased gastric and bowel motility and urinary output

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10
Q

Multiple Ways to assess Pain

A
  • OLDCARTTS
  • OQRSTU
  • Numeric Pain Severity scale
  • Pain/Distress Severity scale
  • Universal Pain Assessment Tool
  • FLACC
  • FACES
  • Brief Pain Inventory
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11
Q

Risk Factors of Cardiovascular Disease

A
  • Family history
  • Increased age
  • Increased BP
  • Elevated Cholesterol
  • High Blood Sugar(DM)
  • Obesity
  • Cigarette Smoking
  • Diet, Sodium
  • Sedentary lifestyle
  • For Females - after menopause
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12
Q

Signs and Symptoms of Potential CV Problem

A
  • pain in neck, jaw, chest, left shoulder and arm, subscapular, and stomach pain
  • Shortness of Breath - dyspnea, orthopnea, paroxysmal nocturnal dyspnea
  • cough
  • diaphoresis (sweating when seated)
  • lightheadedness
  • pain in limbs, ulcers to lower extremities
  • fatigue
  • indigestion/heartburn
  • nausea and vomiting
  • edema
  • pressure…
  • nocturia
  • palpations/dysrhythmia
  • racing heart
  • pre syncope/syncope (fainting)
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13
Q

Assessment of CV System - History

A
  • demographics/SDOH
  • OLDCARTSS
  • current and recent symptoms
  • associated symptoms
  • inquire about respiratory concerns
  • ask about risk factors
  • discuss family history
  • ask past medical history, allergies, and medications
  • social history
  • functional ability (IADLS/ADLS)
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14
Q

Physical Assessment

A

Vital Signs
- start with this
- think about results and compare them
- interpret results in the patient’s own context
- how are the vital signs related to each other and/or if they have an influence
- do findings require urgent action or monitoring

Inspection
- general survey
- skin colour
- respirations
- speech patterns
- size and shape of thorax
- diaphoresis
- fingers ( nail beds, clubbing)
- landmarks
- abnormal pulsations

Palpations of Pulses
- rate, rhythm, strength

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15
Q

Objective Data : Auscultation - Unexpected Heart Sounds

A

Murmurs
- turbulence causing a swooshing or blowing sound
- result of cardiac abnormalities (increased blood velocity, structural valve defects and valve malfunction, abnormal chamber openings)

Bruits
- turbulent flow
- results of partial obstruction sites (carotids, abdominal aortic, renal, iliac, femoral)

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16
Q

Landmarking - PMI

A

Aortic
Pulmonic
ERB
Tricuspid
Mitral

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17
Q

S1+S2

A

S1
- loudest at apex
- AV valve closure ( mitral and tricuspid valves, bet. chambers)
- beginning of systole

S2
- loudest at base
- SL valve closure (aortic and pulmonic valves, out to body/lungs)
- beginning of diastole

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18
Q

Effects of Aging on the Heart

A
  • increased collagen and decreased elastin
  • decreased contractility and HR
  • cardiac valves thicken and become stiffer due to lipid accumulation - valve incompetence or stenosis = murmur
  • decreased number of pacemaker cells in the SA node - bradycardia and heart block
  • decreased control of PNS over the CVS
  • arterial blood vessels thicken and less elastic = high bp
19
Q

When to Perform a Neurovascular Assessment?

A
  • injury/trauma to limb
  • presence of cast or protective barrier
  • surgery to the limb
  • presence of a wound on the limb
  • conditions that can cause poor circulation
    > cigarrete smoking
    > heart failure
    > venous/arterial insufficienct
    > extreme edema
    > hypothermia
  • client complaining about pain and discomfort
20
Q

Arterial vs. Venous Insufficiency

A

Arterial
- pain with exertion
- relieved with short rest
- pale when elevated
Venous
- pain described as aching, dull, and heavy
- swelling increasing as day progresses
- pain and edema relieved when elevated
- varicose veins

21
Q

Peripheral Vascular Assessment

A
  • Movement
  • Temperature
  • Sensation
  • Blanching
  • Colour
  • Edema
  • Pulse
22
Q

Rating Scale: Extent of Pitting Edema

A
23
Q

Palpating Neuro Component of Assessment

A

Peroneal Nerve and Tibial Nerve - movement and sensation

Radial, Ulnar, and Median Nerve - movement and sensation

24
Q

Reynauld’s

A
  • restricts blood flow to finger/toes
  • caused by cold, stress
  • turns white, feels numb
25
Q

Acute Neurovascular Assessment

A
  1. Arterial Occlusion
  2. Deep Venous Thrombosis
  3. Compartment Syndrome

All accompanied with pain

26
Q

Ventilation? Diffusion? Perfusion?

A

Ventilation
- the air going in and coming back out
Diffusion
- gas exchange at the capillaries; movement of co2 and o2
Perfusion
- the ability of the oxygenated blood to reach the lungs, blood flow to the lungs

27
Q

Challenges to the Respiratory System

A

Smoking
- first, second, and third hand
- e-cigarettes and vaping

Environmental Factors
- occupation
- home
- travel

28
Q

Respiratory: Subjective Data

A
  • cough ( are you coughing anything up?…)
  • dyspnea (SOB, SOBOE)
  • chest pain
  • past medical history
  • family history
  • self-care activities
  • allergies
  • immunizations
  • determinants of health
29
Q

Respiratory: Objective Data

A

Inspection
- prior to physical assessment; notice, observe, inspect and have patient interaction
- blue discolouration; deoxygenated blood - cyanosis

Palpation
- chest tendernes (sternum, paravertebral muscles, point tenderness)
- “extra” assessments (if chest x-ray is not possible); chest excursion, tactile fremitus
- abnormal findings (crepitus(air in subcutaneous tissues)

Auscultation
- Suprasternal notch
- Angle of Louis (sternal angle)
- Costal angle
- Scapular, clavicular, axillary lines
- Cervical vertebra #7

30
Q

Auscultation Sounds

A

Normal Sounds:
- bronchial
- vesicular
- bronchovesicular

Abnormal/Adventitious Sounds:
- diminished sounds
- absent sounds
- friction rub
- crackles
- wheezes

31
Q

Auscultation Sounds: Normal Sounds

A

Bronchial
- loud, hollow ‘tubular’ sounds
- high pitched
- considered abnormal if heard over peripheral lung fields
- distinct pause bet. inspiration and expiration
- inspiration to expiration ratio of 1:2 or 1:3

Vesicular
- soft, low pitched
- ‘rustling’ quality with inspiration
- even softer during expiration
- majority of lung sounds
- inspiration/expiration ratio of 3:1

Broncho-Vesicular
- normally hear in the mid-chest
- inspiration/expiration ratio of 1:1

32
Q

Auscultation Sounds: Adventitious Sounds

A

Crackles
- fine crackles are brief, discontinuous, popping lung sounds that are high pitched; atelectasis
- course crackles are brief, discontinuous, popping lung sounds that are lower in pitch, louder, and last longer; pneumonia

Friction Rub
- low-pitched, short, grating sound

Wheeze
- musical sounds caused by narrowing of the airways - asthma

33
Q

Promoting Respirations and Oxygenation

A
  • promote lung expansion
  • prevent stasis of secretions
  • maintain patent airway
  • promote adequate exchange of o2 and co2
34
Q

Developmental Variations - Infants (respiratory)

A
  • irregular is normal
  • nose breathers
  • broncho-vesicular sounds are heard
  • abdominal rises rather than chest
  • after 2 years old, the breathing shifts to intercostal
  • apnea should never exceed 15 seconds
35
Q

Pregnancy (respiratory)

A
  • increase in tidal volume to meet the fetus’ need for o2
  • the diaphragm rises and the costal angle widens
36
Q

Aging - Older Adults (respiratory)

A
  • alveoli tend to fibrose resulting in decreased surface area for gas exchange
  • lung capacity decreases due to muscle weakness and less elasticity
  • more dead space, trapped air, and less vital capacity
  • thoracic spine curves (kyphosis) which gives the appearance of barrel chest
37
Q

Focused Assessment: Subjective Data Collection

A

Assessment of risk factors
- demographic data
- past medical history
- family history
- nutrition and medications

Psychosocial history
Occupation, lifestyle, and behaviours
Functional Assessment

37
Q

Focused Assessment: Subjective Data Collection

A

Assessment of risk factors
- demographic data
- past medical history
- family history
- nutrition and medications

Psychosocial history
Occupation, lifestyle, and behaviours
Functional Assessment

37
Q

Focused Assessment: Subjective Data Collection

A

Assessment of risk factors
- demographic data
- past medical history
- family history
- nutrition and medications

Psychosocial history
Occupation, lifestyle, and behaviours
Functional Assessment

38
Q

Focused Assessment: Subjective Data Collection

A

Assessment of risk factors
- demographic data
- past medical history
- family history
- nutrition and medications

Psychosocial history
Occupation, lifestyle, and behaviours
Functional Assessment

38
Q

Musculoskeletal: Focused Assessment: Subjective Data Collection

A

Assessment of risk factors
- demographic data
- past medical history
- family history
- nutrition and medications

Psychosocial history
Occupation, lifestyle, and behaviours
Functional Assessment

39
Q

Musculoskeletal: Special Circumstances

A

Pathological factors: fractures resulting from disease processes; cancer deterioration of the bone; not from an accident or injury

Pregnancy:
- increased levels of circulatory hormones may increase mobility of joints
- changes in maternal posture; lordosis of low back, shifts back with time
- compensate for enlarging fetus; centre of gravity shifts causes the waddle
- strain or lower back muscles and pain in late pregnancy
- sciatic nerve pain from pressure(take peripheral vascular assessment)
- anterior flexion of neck, slumping of shoulders
- hips and pelvis move forward, joints loosen to deliver

Scoliosis: special tests
- patient standing erect
- patient bending forward
- limb measurement

Polio: the lasting effects
- poliovirus attacks the long bones, disease the growing bones, asymmetrical growth
- postpolio; loses function in leg

Basilar Skull Fracture
- damage to skull including all lobes
- symptoms - battle’s sign which is bruising from bleeding behind ear; raccoon eyes which is bleeding into orbital cavities and cause bleeding into tissues –children are more prone to head injury

40
Q

Muscoskelton Life Span Considerations

A

Nursing 1180 Midterm (1 decks)

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