NCM 101 A Quiz 4

• PAIN: The 5th Vital Sign & Its Assessment
• Purposes of the Physical Examination

  • Obtain baseline data

  • Supplement, confirm, or refute data from the history

  • Help establish nursing diagnoses and plans of care

  • Evaluate physiologic outcomes and progress

  • Make clinical judgments

  • Identify areas for health promotion and disease prevention
• Preparation Guidelines

  o Infection Control

   Hand Hygiene

   Mask*

   Gloves*

   Gowns*

  *as needed
• Environment

  o Provision of privacy

  o Adequate lighting

  o Adequate ventilation

  o Examination tables *

  * as needed
• Positioning

   Manipulation of the client’s body to ensure accessibility of

  the body part to be assessed
• Consider the following before positioning the client

  • Physical strength or energy

  • Mobility

  • Ease of breathing

  • Age

  • Degree of wellness
• Draping

   A piece of cloth, paper or bed linen used to cover parts of

  the body that are not to be assessed
• PHYSICAL EXAMINATION GUIDELINES

   Compare both sides of the body for symmetry, a degree of asymmetry is normal

   If a client is seriously ill, 1st assess the system of the body more at risk for being abnormal

   If a client becomes fatigued, offer rest periods between assessment

   Perform a painful assessment near the end of the examination

   Record results in specific, accepted terms

   Record quick notes
• METHODS USED IN PHYSICAL EXAMINATION

  • Palpation
  • Inspection
  • Percussion
  • Auscultation
• Inspection

  • Deliberate, purposeful, and systematic examination

  • It involves the use of senses (vision, smell & hearing)

  • Assess for: Moisture, color, shape, position, size, symmetry of the body
• Palpation

  • Examination using sense of touch

  • Done by applying light-moderate–deep touch

  • Done using different parts of the hand - finger pads, palmar and dorsal surface
• Palpation includes:

  – Texture

  – Temperature

  – Vibration

  – Position, size, consistency, mobility of organs or masses

  – Distention

  – Pulsation

  – Presence of pain upon pressure
• Percussion

  • Striking body surface to elicit sounds or vibrations

  • Determine the size, shape, and borders of internal organs

  
  

  – Direct —striking body directly

  – Indirect —striking of an object held against the body
• Flat sounds

  – Soft, high pitched, and short duration (e.g., muscle, bone,

  sternum, thigh)
• Dull sounds

  – Medium in intensity, pitch, and duration (e.g., diaphragm,

  pleural effusion, liver)
• Resonant sounds

  – Loud, low pitched, and long duration (e.g., normal lung)
• Hyperresonant sounds

  – Very loud, lower in pitch, and longer in duration (e.g.,

  emphysematous lung)
• Tympanic sounds

  – Loud and musical (e.g., gastric air bubble, intestine, puffed-

  out cheek)
• Auscultation

  • Listening to sounds produced within the body

  • Pitch, intensity, duration, quality

  
  

  – Direct —use of unaided ear

  – Indirect —use of stethoscope
• PAIN

  
  

   A sensation of agony, or suffering due to the stimulation of certain nerve

  endings, emotional suffering such as grief

   The most common reason a person why a person seeks healthcare

   A universal experience

   5th vital sign

  • American Pain Association
• NURSING DEFINITION OF PAIN

   Whatever bodily hurt the patient says he has, existing whenever he says it

  does.

   Cardinal Rule in the care of patient’s with pain is that “ALL PAIN IS

  REAL”, even if the cause is unknown

   Based simply on the patient’s report that it exists
• CLASSIFICATION OF PAIN BY SEVERITY

   ACUTE PAIN

   CHRONIC PAIN
• ACUTE PAIN

  • Pain that has a rapid onset, varies in intensity, and lasts for a brief

  time or up to 6 months

  • Functions – to warn persons of impending injury or disease.

  • Resolves with or without treatment

  • Frightened, anxious, expect relief quickly

  • Self – limiting
• CHRONIC PAIN

  • caused by uncontrolled cancer (intractable pain)

  • can be benign or persistent and lasts for more than 6 months

  • often has periods of remission and exacerbations

  • major cause of psychological and physical disability leading to

  problems such as loss of job, inability to perform simple daily

  activities, sexual dysfunction, and social isolation from family and

  friends

  • often does not show overt symptoms

  • symptoms of chronic pain: fatigue, weight loss, anorexia,

  depression, hopelessness, anger

  • nurse primary goal = reduce the client’s perception of pain
• CLASSIFICATION BY LOCATION

   Superficial or cutaneous

   Deep visceral

   Referred Pain

   Radiating Pain

   Somatic pain

   Intractable pain

   Phantom pain

   Psychogenic pain

   Intermittent pain
• Superficial or cutaneous

  • Pain resulting from stimulation of the skin

  • Characteristic

  – Short duration, localized; usually a sharp sensation

  • Example:

  – Needle stick; small cut or laceration
• Deep visceral

  • Pain resulting from stimulation of internal organs

  • Characteristic

  – Diffuse, may radiate in several directions; duration varies but

  usually lasts longer than superficial pain; pain may be sharp,

  dull, or unique to organ involved

  • Example

  – Crushing sensation; burning sensation
• Referred Pain

  • The pain is perceived at an area other than the site of injury

  • Characteristic

  – Pain is felt in a part of the body separate from the source of

  pain and may assume any characteristic

  • Example

  – An MI may cause referred pain to the jaw, left arm, and left shoulder; kidney stones may refer pain to in the groin area
• Radiating Pain

  • A sensation of pain extending from the initial site of injury to another body part

  • Characteristic

  – Pain feels as though it travels down or along a body part; may be intermittent or constant

  • Example

  – Low back pain from a ruptured intervertebral disc accompanied by pain radiating down the leg from sciatic nerve irritation
• Somatic pain

  • May be deep or superficial. It occurs in the skin, muscles or joints
• Intractable pain

  • It is resistant to cure or relief
• Phantom pain

  • The actual pain felt in a body part that is no longer present
• Psychogenic pain

  • It is primarily due to emotional factors
• Intermittent pain

  • Pain that stops and starts again
• PAIN TRANSMISSION

  1. Transduction
  2. Transmission
  3. Perception
  4. Modulation
• Transduction

  • the phase wherein noxious stimuli trigger the release of biochemical mediators (e.g. prostaglandin, bradykinin, serotonin, histamine, substance P) that sensitize nociceptors.
• Transmission

  • Transmission of pain from the cause of pain to the perception of pain
  • Pain control takes place during the transmission of pain
• Perception

  • Client becomes conscious of the pain
  • Brain interprets the signals and localizes the pain (Nociception)
  • Brain relates impulses to past pain experiences
• Modulation

  • “Descending system”
  • Neurons of the brain send signals or pain killers (e.g. endorphins, GABA) to the area of affectation
  • It inhibits painful ascending stimuli
• THE SEVEN DIMENSION OF PAIN

  1. Physical Dimension
  2. Sensory Dimension
  3. Behavioral Dimension
  4. Sociocultural Dimension
  5. Cognitive Dimension
  6. Affective Dimension
  7. Spiritual Dimension