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NSG 3133 PHYSICAL ASSESSMENT EXAM 2 LATEST VERSION
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NSG 3133 PHYSICAL ASSESSMENT EXAM 2 LATEST VERSION...
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NSG 3133 PHYSICAL ASSESSMENTEXAM 2 LATEST VERSION
acute pain
- recent onset (less than 6 months)
- self-limiting
- tissue damage ends when tissue heals
- increased BP, HR, RR
chronic pain
- persistent (longer than 6 months)
- intermittent or continuous pain
- client adapts
- irritability, depression, withdrawal, insomnia
neuropathic pain
- abnormal processing of sensory input
- occur after injury
- phantom pain: from an amputated limb
- diabetic peripheral neuropathy
nociceptive pain
- somatic (bone, joint, skin or muscle)
- visceral pain (thoracic, pelvic, abdominal)
- referred pain: pain felt in area away from injury
- gallbladder disease may cause referred pain to the right shoulder
pain threshold
- a stimulus is perceived as pain
pain tolerance
,- duration or intensity of pain a person will endure before outwardly responding
- decreased with repeated exposure
self report
- client is most reliable parameter for pain assessment
phantom pain
- usually post-ambulation
- brain interpreted pain
delirium
- a disturbance in attention and awareness
- an acute change from baseline attention and awareness
pain examination
- observe client for posture and behavior that helps relieve pain
- observe facial expressions
- listen for sounds made by client
- measure BP and pulse
- Assess respiratory rate and pattern
- inspect painful site ALWAYS
- light palpations site for tenderness
infants and children
- ability to understand and describe pain increases with age (kids have a hard
time understanding)
- neonate responses to pain are global
- increased HR, hypertension, sweating, decreased oxygenation saturation
older adults
- pain transmission slowed, but felt no differently
- most clients may underreport d/t fear, culture
- clients have a lifetime of experience in coping with pain
, - pain not expected part of aging
limbic system
- emotional brain
- regulates memory and basic emotions
- fear, anger, and sex drive
mental health history
- in the past, have you experienced any behaviors that could indicate a mental
health problem?
- do you have any blood relatives who have behaviors that could indicate a
mental health problem?
personal and psychosocial
- how have you been feeling about yourself?
- how would you describe yourself to others?
- what do you like about yourself?
interpersonal relationships
- how satisfied are you with your interpersonal relationships?
- because of abuse or violence have become common, all clients should be
assessed for abuse
stressors
- what are major stressors in your life?
- how do you deal with stress?
- how have these affected your stress level?
major depression
- an abnormal mood state characterized by a sense of sadness, hopelessness,
worthlessness or despair from loss or tragedy
- interfere with client's ability to work, study, sleep, eat, and enjoy pleasurable
activities
- empty mood, changed appetite, suicidal thoughts
bipolar disorder
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