Health Assessment Week 3

Front 1

How pain travels

Back 1

transmitted from the site of stimulation of peripheral receptors to the spinal cord (transduction), up the spinal cord (transmission) to the cerebral cortex (perception), and back down the spinal cord (modulation)

Front 2

Pain definition

Back 2

"whatever the experiencing person say it is, existing whenever he says it does"

-subjective report is most reliable indicator of pain

Front 3

Nociception

Back 3

term used to describe how noxious stimuli are typically perceived as pain. Four phases:
transduction, transmission, perception, modulation

Front 4

Pain classified by source

Back 4

visceral pain, deep somatic pain, superficial (cutaneous) pain, or referred pain (originates in one location but felt in another)

Equianalgesia: does of one opioid who's pain-relieving effects are equivalent to a dose of another opioid

Front 5

Neuropathic pain

Back 5

pain resulting from a nerve injury in either central or peripheral nervous system. Type of pain that does not follow typical or predictable phases of nociceptive pain

Somatic: superficial (skin) or deep (joints)

Visceral: larger interior organs (kidneys, pancreas)

Front 6

Pain classified by duration

Back 6

Acute: short term and self-limiting, often follows predictable track and ends after injury healed

Persistent: continues for 6 months or longer than expected time of tissue healing, can last for years. intensity of pain doesn't reflect physical findings.

Front 7

Factors affecting experience of pain

Back 7

developmental age

ethnocultural aspects

gender differences

Front 8

Pain Scales

Back 8

Uni-dimensional and intended to reflect pain intensity.

Numeric scales- adult patients

Pediatric scales with pictures

Front 9

Mental Health

Back 9

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.

Front 10

Mental Status

Back 10

degree of competence that a person show in intellectual, emotional, psychological, and personality functioning

Front 11

Considerations for mental status

Back 11

consciousness

language

mood and affect

orientation

attention

memory

abstract reasoning

though process

thought content

perceptions

Front 12

Developmental perspective for infants

Back 12

Must consider consciousness, use of language, attention span, and ability to think abstractly

Front 13

4 components addressed during mental status assessment

Back 13

Appearance- posture, body movements, dress, grooming and hygiene

Behavior- level of consciousness, facial expression, speech, mood and affect

Cognitive functions- orientation, attention span, recent and remote memory, new learning

Thought processes- thought processes, though content, perception, screen for suicidal thoughts

Front 14

Mini mental status exam

Back 14

Quick and easy means of assessing cognitive function. Used to detect dementia and delirium as well as differentiate organic disorders from psychiatric illnesses.

Nipissing District Developmental Screen- kids

ABCT - adults

Front 15

Assessment #1- Inspection

Back 15

refers to visual examination of body (movements and posture) as well as smell.

Front 16

Assessment #2- Palpation

Back 16

Use of nurses hands to feel texture, size, shape, consistency, and location of certain parts of clients body and also identify areas the client reports as being tender or painful

Light palpation (1-2 cm)

Deep palpation (4-7cm)
Fingertips- skin texture, swelling, pulsatility, and lumps

Dorsa of hand- temperature

Base of fingers- vibration

Front 17

Assessment #3- Percussion

Back 17

tapping the persons skin with short, sharp strokes to assess underlying structures by litsening to sound waves heard as 'notes'

Direct: striking hand contacts body

Indirect: striking hand contacts stationary hand

Front 18

Percussion Sounds

Back 18

Resonant sounds are low pitched, hollow sounds heard over normal lung tissue.

Flat or extremely dull sounds are normally heard over solid areas such as bones.

Dull or thudlike sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

Hyperresonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax.

Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax.

Front 19

Characteristics of Percussion Sounds

Back 19

Amplitude: loudness or softness of a sound

Pitch: number of vibrations or cycles per second

Quality: subjective diff. in a sounds distinctive overtones

Duration: length of time the note lingers

Front 20

Assessment #4- Auscultation

Back 20

Act of listening to sounds within body commonly using a stethoscope

Diaphragm: used to hear high pitched sounds

Bell: better to locate low pitched sounds like murmurs and bruits