Health Assessment for Nursing Practice,
7th Edition All Chapters 1-24
factors influencing the pain perception
culture
ethnic variables
family, gender, and age variables
religious beliefs
environment and support people
anxiety, fatigue, other stressors
past pain experience
neuro function
FLACC scale
non-verbal; useful in determining pain in infants, elderly, mentally handicapped
Intensity or Quantity Scale (numeric rating scale)
choose a number from 0-10 that best describes your pain
OLDCARTS Assessment Tool
Onset
Location
Duration
Characteristics
Aggravating/Alleviating Factors
Radiation
Treatment
Severity
chronic pain
probably no physiologic symptoms
body has adapted to the physiologic stress/vital signs do not change
depression, fatigue, decreased level of functioning, withdrawn
acute pain
immobilization of body part
behavioral changes
BP/pulse changes
, respiratory rate changes
sweating
nonopioids
acetaminophen
NSAIDs - ibuprofen, aspirin
acetaminophen/Tylenol
acts as an analgesic
little anti-inflamm properties
no more than 4000 mg daily; 3000 mg daily recommended bc of liver
NSAIDs - ibuprofen/aspirin
blocks production of prostaglandins
anti-inflamm properties
give with food
nonopioids
use for mild to moderate pain
opioids
morphine sulfate
codeine
fentanyl
hydromorphone
hydrocodone
oxycodone
opioids
used for moderate to severe pain, smooth muscle relaxation, monitor for respiratory depression
side effects of opioids
nausea, sedation, constipation, orthostatic hypotension, urinary retention
adjuvants/coanalgesics
antidepressants, anticonvulsants, benzos, corticosteroids, antiemetics; enhance effects of
analgesics by providing additional pain relief; reduce side effects or decrease anxiety
JCAHO standards
assert that clients have the right to appropriate assessment and management of pain
-pain is assessed in all clients
-initial assessment and regular reassessment of pain
-education of providers in pain assessment and management
, -education of clients/families in roles in managing pain and limitations and side effects of
treatments
SBP
Systolic blood pressure; top number
DBP
diastolic blood pressure; bottom number
Orthostatic hypotension
BP changes when pt changes position (lying to sitting to standing); a systolic blood pressure
decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg
within three minutes of standing
pulse pressure
difference between diastolic and systolic pressures (should be 30-40 mm Hg)
tachycardia
rapid heartbeat (over 100)
bradycardia
slow heartbeat (under 60)
fever
high temperature
hyperthermia
high body temperature
hypothermia
low body temperature
tachypnea
rapid breathing
bradypnea
slow breathing
sphygmomanometer
an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff that
is applied to the arm and connected to a column of mercury next to a graduated scale, enabling
the determination of systolic and diastolic blood pressure by increasing and gradually releasing
the pressure in the cuff.
, stethoscope
a medical instrument for listening to the action of someone's heart or breathing, typically having
a small disk-shaped resonator that is placed against the chest and two tubes connected to
earpieces.
otoscope
an instrument designed for visual examination of the eardrum and the passage of the outer ear,
typically having a light and a set of lenses.
opthalmoscope
an instrument for inspecting the retina and other parts of the eye.
dysrhythmia
abnormal rhythm
pulse deficit
difference between heart beats and pulsations at the periphery; determined by simultaneous
palpation at the radial artery and auscultation at the PMI, near the heart apex
apical pulse
pulse found over the heart
hypoxemia
low oxygen
hypertension
SBP above 150 mm hg
hypotension
SBP below 90 mm hg
mental health
relative state of mind in which a person who is healthy is able to cope with and adjust to daily
stresses in an acceptable way; the degree to which a person is able to fulfill the cultural
expectations of his/her society
perception
It is the ___________ of a recent life event that determines a person's emotional or
psychological reaction to it
mental status
degree of competence a person shows in intellectual, emotional, psychological, and personality
function
7th Edition All Chapters 1-24
factors influencing the pain perception
culture
ethnic variables
family, gender, and age variables
religious beliefs
environment and support people
anxiety, fatigue, other stressors
past pain experience
neuro function
FLACC scale
non-verbal; useful in determining pain in infants, elderly, mentally handicapped
Intensity or Quantity Scale (numeric rating scale)
choose a number from 0-10 that best describes your pain
OLDCARTS Assessment Tool
Onset
Location
Duration
Characteristics
Aggravating/Alleviating Factors
Radiation
Treatment
Severity
chronic pain
probably no physiologic symptoms
body has adapted to the physiologic stress/vital signs do not change
depression, fatigue, decreased level of functioning, withdrawn
acute pain
immobilization of body part
behavioral changes
BP/pulse changes
, respiratory rate changes
sweating
nonopioids
acetaminophen
NSAIDs - ibuprofen, aspirin
acetaminophen/Tylenol
acts as an analgesic
little anti-inflamm properties
no more than 4000 mg daily; 3000 mg daily recommended bc of liver
NSAIDs - ibuprofen/aspirin
blocks production of prostaglandins
anti-inflamm properties
give with food
nonopioids
use for mild to moderate pain
opioids
morphine sulfate
codeine
fentanyl
hydromorphone
hydrocodone
oxycodone
opioids
used for moderate to severe pain, smooth muscle relaxation, monitor for respiratory depression
side effects of opioids
nausea, sedation, constipation, orthostatic hypotension, urinary retention
adjuvants/coanalgesics
antidepressants, anticonvulsants, benzos, corticosteroids, antiemetics; enhance effects of
analgesics by providing additional pain relief; reduce side effects or decrease anxiety
JCAHO standards
assert that clients have the right to appropriate assessment and management of pain
-pain is assessed in all clients
-initial assessment and regular reassessment of pain
-education of providers in pain assessment and management
, -education of clients/families in roles in managing pain and limitations and side effects of
treatments
SBP
Systolic blood pressure; top number
DBP
diastolic blood pressure; bottom number
Orthostatic hypotension
BP changes when pt changes position (lying to sitting to standing); a systolic blood pressure
decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg
within three minutes of standing
pulse pressure
difference between diastolic and systolic pressures (should be 30-40 mm Hg)
tachycardia
rapid heartbeat (over 100)
bradycardia
slow heartbeat (under 60)
fever
high temperature
hyperthermia
high body temperature
hypothermia
low body temperature
tachypnea
rapid breathing
bradypnea
slow breathing
sphygmomanometer
an instrument for measuring blood pressure, typically consisting of an inflatable rubber cuff that
is applied to the arm and connected to a column of mercury next to a graduated scale, enabling
the determination of systolic and diastolic blood pressure by increasing and gradually releasing
the pressure in the cuff.
, stethoscope
a medical instrument for listening to the action of someone's heart or breathing, typically having
a small disk-shaped resonator that is placed against the chest and two tubes connected to
earpieces.
otoscope
an instrument designed for visual examination of the eardrum and the passage of the outer ear,
typically having a light and a set of lenses.
opthalmoscope
an instrument for inspecting the retina and other parts of the eye.
dysrhythmia
abnormal rhythm
pulse deficit
difference between heart beats and pulsations at the periphery; determined by simultaneous
palpation at the radial artery and auscultation at the PMI, near the heart apex
apical pulse
pulse found over the heart
hypoxemia
low oxygen
hypertension
SBP above 150 mm hg
hypotension
SBP below 90 mm hg
mental health
relative state of mind in which a person who is healthy is able to cope with and adjust to daily
stresses in an acceptable way; the degree to which a person is able to fulfill the cultural
expectations of his/her society
perception
It is the ___________ of a recent life event that determines a person's emotional or
psychological reaction to it
mental status
degree of competence a person shows in intellectual, emotional, psychological, and personality
function
