ncma 219

• Pain is an unpleasant sensory and emotional experience primarily associated with tissue damage or described in terms of such damage
• Pain tolerance is the amount of pain a person can endure without having it interfere with their normal functioning
• Types of pain:

  • Acute Pain: sudden onset, usually the result of clearly defined causes such as injury, resolves with the healing of underlying cause
  • Chronic Pain: persists for weeks or months, usually caused by underlying conditions such as arthritis
  • Cancer Pain: occurs from pressure on nerves and organ blockage to blood supply or metastasis of the bone
  • Somatic Pain: pain in skeletal muscles, ligaments, and joints
  • Visceral Pain: pain from smooth muscle and organs
  • Neuropathic Pain: pain due to damage or lesion in the nerves
  • Intractable Pain: pain of high resistance to pain medications
  • Idiopathic Pain: pain of unknown cause or origin
• Pathophysiology of Pain:

  • The source of pain stimulates the peripheral nerve endings (nocireceptors) which transmit the sensation to the central nervous system
  • Types of nociceptors:
  • Mechanosensitive nociceptors (of A-Delta Fibers): sensitive to intense mechanical stimulation (e.g., pinching)
  • Thermosensitive nociceptors (of A-Delta Fibers): sensitive to intense heat or cold
  • Polymodal nociceptors (C-Fibers): sensitive to stimuli of mechanical, thermal, or chemical nature
• Character Description of pain:

  • Onset: when the pain started (acute or chronic)
  • Location: specific region/parts of the body
  • Duration: when the pain usually occurs or subsides
  • Severity: describes the intensity of the pain (e.g., bearable or unbearable)
  • Patterns: how often the pain attacks or when it usually occurs (e.g., night time)
  • Associating Factors: factors that might contribute to the pain (e.g., post-op)
• Types of wounds include:

  • Incision: a deep or shallow tear from a sharp object with clean-cut edges
  • Contusion: a closed wound caused by a blow from a blunt instrument, resulting in bruising
  • Abrasion: an open wound from a surface scrape
  • Puncture: an open wound caused by sharp objects penetrating skin and underlying tissues
  • Laceration: an open wound from accidents causing tissues to be torn apart with jagged edges
  • Avulsion: an open wound where a chunk of bone attached to the tendon is torn off
  • Pressure Injuries: also known as pressure ulcers, decubitus, or bedsores, usually over bony prominences due to force or movement
• Types of wound healing:

  • Primary Intention: minimal or no tissue loss with tissue surfaces approximated (closed)
  • Secondary Intention: considerable tissue loss, longer repair time, greater scarring, and susceptibility to infection
  • Tertiary Intention: wounds left open for 3-5 days to allow resolution of edema or infection before closure with sutures or adhesives
• Nursing responsibilities in specimen collection:

  • Provide client comfort, privacy, and safety
  • Explain the purpose and procedure clearly to reduce anxiety
  • Use correct aseptic technique to prevent contamination
  • Note relevant information on the laboratory requisition slip
  • Transport the specimen promptly to the laboratory
  • Report abnormal laboratory results to the healthcare provider timely
• Collecting stool specimens (Fecalysis) purpose:

  • To analyze dietary products, digestive secretions, ova, parasites, bacteria, viruses, and occult blood
• FLACC Behavioral Scale:

  • Face, Legs, Activity, Cry, Consolability
  • Used for assessing pain in nonverbal patients, scored from 0 to 2 in each category
• Assessment tool 9-2:

  • Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale
  • Revised FLACC can be used for children with cognitive disabilities
• Pain Tolerance


  Amount of pain a person can endure without having it interfere with their normal functioning
• ASSESSING PAIN


  1. COLDSPA

  2. Character - Description of pain

  3. Onset - When was the pain started (Acute or Chronic)

  4. Location - Specific region/parts of body

  5. Duration - When is usually pain occur or subsides

  6. Severity - Describe the intensity of the pain

  7. Patterns - how often does the pain attack or when it usually occurs

  8. Associating Factors - Factors that might contribute to the pain
• Types of Pain


  • Acute Pain
  • Chronic Pain
  • Cancer Pain
  • Somatic Pain
  • Visceral Pain
  • Neuropathic Pain
  • Intractable Pain
  • Idiopathic
• Pathophysiology of Pain

  1. The source of pain stimulates the peripheral nerve endings (nocireceptors) which transmits the sensation to the central nervous system

  2. Mechanosensitive nociceptors (of A-Delta Fibers) - sensitive to intense mechanical stimulation

  3. Thermosensitive nociceptors (of A-Delta Fibers) - sensitive to intense heat or cold

  4. Polymodal nociceptors (C-Fibers) - sensitive to stimuli of mechanical, thermal or chemical in nature
• ADULTS

  1. Maintain a quiet and calm environment that is comfortable for the patient being interviewed

  2. Maintain client’s privacy and ensure confidentiality

  3. Ask the questions in an open-ended format

  4. Listen carefully to the client’s verbal description and quote the term used

  5. Watch for the client’s facial expressions and grimaces during the interview

  6. DO NOT put words in the client’s mouth

  7. Ask the client about past experiences with pain

  8. Believe the client’s expression of pain

  9. Avoid a judgmental approach to the client
• Nursing Intervention on Pain

  1. NONPHARMACOLOGIC - Pain management without the use of medication

  2. PHARMACOLOGIC- Pain management with the use of medication
• Specimen collection

  1. Explain the purpose of the specimen collection and the procedure for obtaining the specimen

  2. Use the correct procedure for obtaining a specimen or ensure that the client or staff follow the correct procedure

  3. Note relevant information on the laboratory requisition slip

  4. Transport the specimen to the laboratory promptly

  5. Report abnormal laboratory results to the healthcare provider in a timely manner consistent with the severity of the abnormal results
• Collecting Stool Specimens

  1. To analyze for dietary products and digestive secretions

  2. To detect the presence of ova and parasites

  3. To detect the presence of bacteria and viruses

  4. To determine the presence of occult (hidden) blood that may indicate bleeding
• Collecting Urine Specimen

  To determine the presence of microorganisms, the type of organisms, and the antibiotics to which the pathogen are sensitive
• Implementation for Collecting Stool Specimens

  1. Before obtaining the specimen, determine the reason for collection

  2. Wear necessary PPE prior to collection of specimen

  3. Instruct client to defecate in a clean bedpan or bedside commode

  4. Do not contaminate the specimen with urine or menstrual discharge

  5. Do not place toilet tissue in the bedpan after defecation

  6. Let the client notify the nurse as soon as possible after defecation

  7. Scoop 1 inch or 2.5cm for firm stool, 15-30mL if stool is liquid

  8. Ensure that the specimen container is properly labeled

  9. Do handwashing and send the collected specimen to the laboratory promptly

  10. Document and record the procedure
• Before Collecting Urine Specimen

  1. Determine the client's ability to provide urine

  2. Assess the presence of conditions that may affect the production and quality of urine
• Implementation for Cleaning Female Clients

  Spread the labia minora with one hand and use towelettes to cleanse the area
• Implementation for Collecting Urine Specimen for Ambulatory Clients

  1. Direct or assist the client to the bathroom

  2. Ask the client to wash and dry the genitals and perineal area with soap and water

  3. Ask the client if sensitive to antiseptic or cleaning agent

  4. Instruct client on how to clean the urinary meatus with antiseptic towelettes
• Cleaning the urinary meatus and penis for male clients

  If uncircumcised, retract the foreskin slightly to expose the urinary meatus. Using circular motion, clean the urinary meatus and the distal portion of the penis. Clean several inches down the shaft of the penis. RATIONALE: this cleans from the area of least contamination to the area of greatest contamination
• Cleaning the perineal area for female clients

  Spread the labia minor with one hand and use one towelette to cleanse one side of the labia minora. Use another towelette for cleaning the other side of the labia minora. Use the third towelette to clean over the urethra. Always cleanse the perineal area from the front to back and discard the towelettes. RATIONALE: Cleaning from front to back cleans the area of least contamination to the greatest contamination
• Collecting urine specimen

  Instruct client to start voiding. Catch the urine during midstream. Place the specimen container into the midstream of urine and collect the specimen, taking care not to touch the container to the perineum or genital. Cap the container tightly, touching only the outside of the container and the cap. If necessary, clean the outside of the container with disinfectant. Remove and discard the gloves. Perform hand hygiene. RATIONALE: Bacteria in the distal urethra and at the urinary meatus are cleared by the first few millimeters of urine expelled. It is important to avoid contaminating the interior of the specimen container and the specimen itself to avoid inaccurate lab results. Transient bacteria may be transferred in the specimen. This prevents contamination or spilling of the specimen. This prevents transfer of microorganisms to others
• Collecting urine specimen for indwelling catheter

  Apply clean gloves. If there is no urine in the catheter, clamp the drainage tubing. Wipe the area where the Luer-Lok syringe will be inserted with a disinfectant swab. Insert the Luer-Lok syringe at a 90 degree angle into the needleless port. Withdraw the required amount of urine. Transfer the urine to the specimen container. Unclamp the catheter. Discard the syringe in an appropriate sharps container. Cap the container. Remove gloves and discard
• Collecting urine specimen for non-ambulatory clients

  Apply clean gloves. Wash the perineal area with soap and water, rinse and dry. Assist the client onto a clean commode or bedpan. Remove and discard gloves. Perform hand hygiene. Open the clean-catch kit, taking care not to contaminate the inside of the specimen container or lid. Apply clean gloves. Clean the urinary meatus and perineal area. Collect the specimen. Label the specimen and transport it to the laboratory. Arrange the specimen to be sent to the laboratory immediately. Document the pertinent data. RATIONALE: Assume a normal anatomic position for voiding facilitates urination. It is important to maintain sterility of the specimen container to prevent contamination of the specimen. Bacterial culture must be started immediately before any contamination organisms can grow and multiply and produce false reports
• Collecting Sputum Specimen

  1. Assess the client’s ability to produce sputum

  2. Assess the client's current condition

  3. Offer mouth care

  4. Collect sputum in the morning

  5. Do hand hygiene and wear appropriate PPE

  6. Ask the client to cough up sputum

  7. Ask the client to expectorate sputum into the specimen container

  8. Offer mouthwash or oral care

  9. Label and transport the specimen to the laboratory

  10. Document the procedure and chart characteristics
• Collecting Sputum Specimen

  • For culture and sensitivity to identify a specific microorganisms and its drug sensitivities
  • For cytology to identify the origin, structure, function, and pathology of cells
  • For acid-fast bacillus (AFB) to identify the presence of tuberculosis
  • To assess the effectiveness of therapy
• Urine collection

  1. Transfer the urine to the specimen container

  2. Unclamp the catheter

  3. Discard the syringe in an appropriate sharps container

  4. Cap the container

  5. Remove gloves and discard and perform hand hygiene

  6. Label the container and send the specimen to the lab
• Urine collection

  • 3mL for a routine urinalysis
• Collecting Wound Drainage Specimen

  • To identify microorganisms causing infection and antibiotics sensitivity
  • To evaluate effectiveness of antibiotic therapy
• Collecting Wound Drainage Specimen

  1. Assess appearance of the wound and surrounding tissue

  2. Client complaints of pain or discomfort

  3. Signs of infection

  4. Introduce yourself and discuss the procedure

  5. Perform hand hygiene and observe infection prevention

  6. Provide client privacy

  7. Remove the dressing

  8. Determine amount, color, consistency, and odor of drainage

  9. Discard dressing carefully

  10. Open sterile dressing set

  11. Assess the wound

  12. Cleanse the wound using aseptic technique
• Types of Wounds

  • Incision
  • Contusion
  • Abrasion
  • Puncture
  • Laceration
  • Avulsion
  • Pressure Injuries
• Wound- is a break or tear in skin or bodily tissues
• Wound Care

  1. Remove the gloves and perform hand hygiene

  2. Open the sterile dressing set

  3. Assess the wound

  4. Cleanse the wound using aseptic technique

  5. Apply clean gloves

  6. If a topical antimicrobial ointment is applied, wipe and irrigate to remove it

  7. Clean the wound with normal saline solution until all exudate has been removed

  8. After cleansing apply a sterile gauze pad to the wound

  9. Remove gloves and perform hand hygiene

  10. Obtaining Aerobic Culture

  11. Apply clean gloves

  12. Open the specimen tube and place the cap upside down on a firm, dry surface

  13. Rotate the swab back and forth over clean areas of granulation tissue

  14. DO NOT USE pus or exudates to culture

  15. Avoid touching the swab to intact skin at the wound edges

  16. Return the swab to the culture tube

  17. Crush the barrier to the inner compartment containing the transport medium

  18. If a specimen is required from another site, repeat the steps

  19. Obtaining Anaerobic Culture

  20. Apply clean gloves

  21. Insert a sterile 10-mL syringe into the wound

  22. Attach the needle to the syringe and expel all air

  23. Immediately inject the drainage into the anaerobic culture tube

  24. Label the tube or syringe appropriately

  25. Remove and discard gloves, perform hand hygiene

  26. Send the tube or syringe of drainage to the laboratory immediately

  27. Dress the wound and document the procedure done along with pertinent information

  28. Apply any ordered medication to the wound

  29. Cover the wound with sterile dressing

  30. Remove gloves and perform hand hygiene
• Types of wounds

  • Open wound: often from accidents causing tissues to be torn apart; edges are jagged
  • Avulsion: Open wound where a chunk of bone attached to the tendon is torn off
  • Pressure Injuries: AKA pressure ulcers, decubitus, pressure sores, bedsores. Injury to the skin or underlying tissues usually over bony prominences as a result of force alone or in combination with movement
• Wound cleaning assessment


  Client allergies, wound appearance and size, amount and character of exudates, client complaints and discomfort, time of last pain medication, signs of infection