Asks the patient to choose a number that rates the level of pain for each painful site,
with 0 being no pain and the highest anchor 10 indicating the worst pain ever
Give this one a try later!
Numeric Rating Scales
Still have to know about medical dx
Medical DX: etiology of disease, biophysical signs and symptoms, curing disease
Nursing DX: Impact of health problem of whole person not just physical. Individual
response to the problem, learning concerns, grieving, changes, complications
Give this one a try later!
, Medical vs. Nursing Diagnosis
Adult: 50-100/min
Adolescent: 60-90/min
School Age: 75-100/min
Preschool: 80-110/min
Toddler: 90-140/min
Infant: 120-160/min
Give this one a try later!
Normal Pulse Rates
Look at VS as a whole
-rapid HR & BP may give you clues to what is going on
-value seems off take it again
-age affects normal values
Give this one a try later!
Assessment of Vitals Key Points
Hypoventilation
Hypoxia
Decreased cough
Atelectasis
Give this one a try later!
, Pulmonary
The pain impulse moves from the spinal cord to the brain.
Give this one a try later!
Transmission
Asks the patient to rate the pain within the past 24 hours using graduated scales (0-10)
with respect to its impact on areas such as mood, walking ability, and sleep
Give this one a try later!
Brief Pain Inventory
WHERE is your pain
WHEN did it start
WHAT does it feel like
HOW MUCH pain do you have now
WHAT MAKES IT BETTER OR WORSE
HOW does pain limit your ADL's
HOW do you usually behave when in pain
HOW would others know you're in pain
WHAT does this mean to you
WHY do you think you are having pain
Give this one a try later!
, Initial Pain Assessment
Sense of touch
Texture, temperature, moisture, organ location and size, swelling, vibration or
pulsation, rigidity or spasticity, crepitation, lumps or masses, presence of tenderness
or pain
Builds on info from inspection
Uses fingertips, grasping action, dorsa of hands and base of fingers
Touch gently and slowly
Give this one a try later!
Palpation
Very soft, high pitched, dead stop, absolute dullness, very short
ie, when no air is present (muscle, bone, tumor)
Give this one a try later!
Percussion Notes
FLAT
Pain lasting 6 months or longer (could be years), malignant/cancer, or non-malignant
(arthritis, low back pain, fibromyalgia) Behaviors include adapting to pain, and
persons with chronic pain may not indicate pain is present. ALWAYS ASK!
Give this one a try later!
with 0 being no pain and the highest anchor 10 indicating the worst pain ever
Give this one a try later!
Numeric Rating Scales
Still have to know about medical dx
Medical DX: etiology of disease, biophysical signs and symptoms, curing disease
Nursing DX: Impact of health problem of whole person not just physical. Individual
response to the problem, learning concerns, grieving, changes, complications
Give this one a try later!
, Medical vs. Nursing Diagnosis
Adult: 50-100/min
Adolescent: 60-90/min
School Age: 75-100/min
Preschool: 80-110/min
Toddler: 90-140/min
Infant: 120-160/min
Give this one a try later!
Normal Pulse Rates
Look at VS as a whole
-rapid HR & BP may give you clues to what is going on
-value seems off take it again
-age affects normal values
Give this one a try later!
Assessment of Vitals Key Points
Hypoventilation
Hypoxia
Decreased cough
Atelectasis
Give this one a try later!
, Pulmonary
The pain impulse moves from the spinal cord to the brain.
Give this one a try later!
Transmission
Asks the patient to rate the pain within the past 24 hours using graduated scales (0-10)
with respect to its impact on areas such as mood, walking ability, and sleep
Give this one a try later!
Brief Pain Inventory
WHERE is your pain
WHEN did it start
WHAT does it feel like
HOW MUCH pain do you have now
WHAT MAKES IT BETTER OR WORSE
HOW does pain limit your ADL's
HOW do you usually behave when in pain
HOW would others know you're in pain
WHAT does this mean to you
WHY do you think you are having pain
Give this one a try later!
, Initial Pain Assessment
Sense of touch
Texture, temperature, moisture, organ location and size, swelling, vibration or
pulsation, rigidity or spasticity, crepitation, lumps or masses, presence of tenderness
or pain
Builds on info from inspection
Uses fingertips, grasping action, dorsa of hands and base of fingers
Touch gently and slowly
Give this one a try later!
Palpation
Very soft, high pitched, dead stop, absolute dullness, very short
ie, when no air is present (muscle, bone, tumor)
Give this one a try later!
Percussion Notes
FLAT
Pain lasting 6 months or longer (could be years), malignant/cancer, or non-malignant
(arthritis, low back pain, fibromyalgia) Behaviors include adapting to pain, and
persons with chronic pain may not indicate pain is present. ALWAYS ASK!
Give this one a try later!
