Exam Review
types of pain - ANS ✔✔:visceral: from larger interior organs (stretching, tumor, ischemia,
distension, severe contracting), transmitted by ascending nerve fibers of autonomic system;
deep somatic pain: from blood Bessel, joints, tendons, muscles, and bone (may be from
pressure, trauma, ischemia);
cutaneous pain: derived from skin surface and subcutaneous tissues;
psychogenic pain/ neuropathic pain;
referred pain: felt at particular location but originates from visceral or somatic structures; pain
can be acute or chronic
Assessment of pain - ANS ✔✔PQRSTU (provocatuve or palliative, quality or quantity, region or
radiation, severity, timing, understand); OLDCARTS (onset, location, duration, characteristics,
aggravating, relieving, timing, severity); short form mcgill (intensity rating), numeric, verbal
descriptor, visual analog, descriptor scale
Older adult presentation of pain: - ANS ✔✔pain is not normal process of aging, older adults
may fear becoming dependent, invasive procedures, pain med, financial burden; pain producing
conditions; behavioral clues: changes in dressing or activities, slowness or rigidity, fatigue, look
for sudden confusion
interviewing techniques older adult - ANS ✔✔take more time, adjust pace, thoughts may
wander, may become tired or fatigued, more info to tell, hearing impaired (speak face to face
and use written communication if needed), may take time to figure out why person has come in
for examination, always determine reason for seeking care
interviewing techniques culture - ANS ✔✔being aware of maintaining cultural norms, privacy
and modesty
communication barriers: working with or without interpreters, touch conveys various meanings
cross culturally, avoid using family members and children as interpreters
, Beginning and ending interviews for health assessment: - ANS ✔✔establish trust and rapport,
open ended questions, ensure privacy; closing: summary and final review, end gracefully, ask if
anything else want to talk about
Subjective versus Objective Data: - ANS ✔✔subjective data: what patient says about themselves
during history taking; objective data: what is observed when inspecting, percussing, palpating,
and auscultating
Documenting patient responses and patient history in health assessment - ANS ✔✔:
documenting means recording your assessment in the medical record, who what where when
how often how many how tolerated
SBAR communication: - ANS ✔✔Situation (providing specific info related to patient issue),
Background (providing context and assessment data relative to patient issue), assessment
(nurse's interpretation of data relative to patient issue); Recommendation (Expectation of
physicians orders relative to patient issue)
Dietary Assessment - ANS ✔✔diet history and intake, physical exam for clinical signs,
anthropometric measures, lab tests; dietary intake assessment: 24 diet recall, food frequency
questionnaire, food diary, direct observation, calorie count
Skin assessment - ANS ✔✔color, temperature, moisture, edema, mobility and turgor (reflects
elasticity of skin), vascularity and bruising
Normal Vital Signs for an Adult - ANS ✔✔pulse: 60-100, respirations: 10-20, bp: 90-120/60-80,
oxygen: above 95, temp: 97.6-99.6
Systolic and Diastolic: - ANS ✔✔systole: hearts contraction, blood pumped from ventricles fill
pulmonary and systemic artieres, one third of cardiac cycle; diastole: ventricles relax and fill
with blood (atrial systole)