Module 1 Part A General Survey and Pain Assessmen

NRSG 2220 Module 1 Part A: General Survey and Pain Assessment Sept 03 Getting Started: General Survey and Pain Assessment General Survey: Looking at a patient through the eyes of a professional nurse. ● Provides clues to overall health ● Begins the moment of contact ● First impressions ● Challenge your observational skills ● Usually includes vital signs, height and weight. What to observe for: ● Signs of distress ● Stature, build ● Dressing and grooming ● Posture, gait, coordination ● Eye contact ○ Can they make eye contact with you? ● Level of consciousness, mood ● Speech patterns ○ Tells you about developmental level, ethnicity, or even level of education ● Vision or hearing problems ● Nutritional state ○ Good thing to look at is hair, healthy hair indicates good protein stores in their body ● Significant others accompanying patient Picture of Child ● What do you see? ○ Nutritional Status→ Chubby, typical of healthy toddler ○ Musculoskeletal development→ The child is starting to walk and hold onto things. Holding on to things is indicative of mental status (holding on for safety) ○ Respiratory→ Color is good, no trouble breathing ○ Environment → Clothing is appropriate and clean, she seems to be content and room seems to be clean and hazard free. Pain Assessment Pain in general is considered the 5th vital sign The Pain Experience ● ● Pain is a subjective experience. You cannot experience the pain the patient is experiencing ○ Highly individual ○ Ethnocultural considerations Expression of pain may not be consistent with degree of pain. Caring for the Patient in Pain ● Must believe that the pain is real and assess all aspects of pain ● Best indicator of pain is patient reporting to you that they have pain ● Important to remember the Joint Commission which sets standards as to what you as a healthcare provider must do for pain management. One of the standards is a pain rating goal for them. Example on a scale of 1-10 what is your pain? What would you like your pain to go down to? 0,1, or 2? ● Goal ○ Reduce or eliminate pain ○ Patient management of pain relief program to resume normal lifestyle Characteristic of Pain ● Duration of Pain ○ Acute: rapid onset, varies with intensity, protective in nature ○ Chronic: Can be intermittent or persistent, long-standing pain, interferes with ability to function ○ Acute on chronic: Someone who has chronic pain on typical level and acute exacerbation overlying. Deal with acute pain immediately and then chronic pain ○ Remission and Exacerbation: ■ Remissions: No symptoms right now, can come out of remission ■ Exacerbation: Symptoms can reappear and in fact get worse ● Source of Pain ○ Cutaneous or Superficial ■ Cutaneous: Pain at skin level for example papercut. Because many nerve endings are at superficial level, so it can be very painful ■ Somatic: Pain that comes from tendons, ligament, bones, vessels, and nerves. For example if you sprain your ankle. Tends to be more diffuse (hard to pinpoint) pain may also be scattered ○ Visceral: Originates from body organs, pain will be in general region of organ, poorly localized. For example, stomach pain is not directly over where stomach is, but in general region of abdomen. ● Etiology or Type of pain: ○ Referred Pain: Pain that is perceived in an area distant from where the pain is originating. Example, MI patient might not have pain in chest but pain in neck, arm, or shoulder. ○ Neuropathic Pain: Injury to peripheral or central nerve, example is pain in neck caused by compression in vertebrae. Pain is wherever those nerves are innervating. ○ Intractable Pain: Pain that is resistant to interventions. ○ Phantom Pain: Often experienced by people who have had amputation. It is thought that the brain keeps sensory representation from limb even though it is not still there. ○ Psychogenic Pain: Pain without a physical cause, it is thought that pain probably has both a physical and psychological origin. Significant mental event can cause pain. Responses to Pain ● Voluntary behavioral responses ○ Move away from stimuli, move away from you when you go to palpate abdomen ○ Grimacing/moaning ○ Guarding painful area ● Involuntary physiologic responses ○ Sympathetic responses (More typical response) ■ BP, pulse, and respiratory rate increases ■ Pupils dilate ■ Muscles tense ■ May get pale and start sweating ○ If the pain is sustained deep and severe pain, the parasympathetic responses kick in. Does the opposite of sympathetic responses ■ BP and pulse decrease ■ RR still goes up ■ Pupils may constrict ■ Nausea and vomiting ● Psychological Response ○ Patient might withdraw and get anxious ○ Might not want to eat ○ Depressed, feeling of hopelessness Pain Assessment ● Pt’s verbalization/Description of Pain ○ Many aspects of pain to assess ● Symptoms evaluation mnemonics ○ COLD ERA ■ Character of the complaint, pain etc. ● How does Pt describe pain? Stabbing, crushing, burning? ● Severity of pain ● Temporal sequence: how does pain wax and wane over 24 hrs? ■ Onset of the symptom ● When did the pain start? ■ Location of the complaint ● Where is pain? ● Is there radiation or in one spot? ■ Duration of the problem ● How long have you have pain? ● ■ Exacerbated by what? ● What makes it worse or aggravates it? ■ Relieved by what? ● What do they do to relieve it? ■ Associated symptoms problem ● What happens at the same time as pain? Are you nauseous at the same time? ○ OLD CARTS ■ Onset ■ Location ■ Duration ■ Character ■ Aggravating Factors/Associated Symptoms ● Important to remember this is both Aggravating and Associated ○ What makes it worse and what happens when you have pain? ■ Relieving Factors ■ Temporal Factors ● Temporal sequence ■ Severity Focused Assessment Guide 35-1 pg. 1123 Pain Assessment Tools: These four are found all over the place ● Scales only assesses severity of pain, does not eliminate need to assess other aspects ● ● ● ● Wong Baker FACES Pain Rating Scale ○ Often used with children, older adults, or those who can’t read/language barrier ○ Easy to point at smiley faces ○ Has several languages on it ○ Includes how much the pain in interferes with normal functioning 0-10 Numeric Pain Distress Scale ○ In addition to the numbers, it includes colors (0-green, 10-red) ○ Color helps pt to identify where pain is Visual Analogue Scale ○ There are no ratings, continuous line ○ Ask pt to point or mark with pen where their pain is, and use same scale after interventions to measure progress ○ Not as widely used Abbey Pain Scale ○ Used for pt with dementia or those who cannot verbalize ○ Filled out as clinician: ■ Is pt vocalizing pain? ■ Change in body language? ■ Behavior changes? ○ You get a number at the end after adding up each categories that guides you as to what treatment to use. Pain Relief Measures ● Pharmacologic-Analgesics ○ Not always the answer. ● Nonpharmacologic ○ Distraction ■ Music ■ Humor ■ Imagery ○ Relaxation ○ Cutaneous Stimulation ■ Massage, Applying heat or cold packs or even Acupressure ○ Therapeutic Touch ■ Should not be minimized. Helps people to feel more comfortable and improves sense of wellbeing. NANDA (North American Nursing Diagnosis Association) Nursing Diagnoses ● Pain: Acute Postoperative ● Pain (name site) ○ Neck Pain, Leg Pain ● Pain ○ Pain in general ● Chronic Pain ○ Chronic pain is different in how you treat it than other types of pain. Example: Pt has appendicitis, doctor treats appendicitis and nurse treats how pt is feeling due to appendicitis or complications of appendicitis.