Health Assessment and Data Collection

Data Collection and Pain Assessment

• Health assessment is a systematic method for gathering and analyzing data to plan patient-centered care.
• Physical examination uses techniques to collect objective data from head to toe.
• Data collection must be systematic and continuous to prevent omitting significant information and reflect a client's changing health status.

Types of Collected Data

• Subjective Data (Stated): Refers to symptoms or covert data; verbal statements from the patient during an interview. It can only be described or verified by the patient.
  • Includes biographical data, reasons for seeking care, history of current health concerns, past health history, family health history, lifestyle/health practices profile, and developmental level.
• Objective Data (Observed): Refers to signs or overt data; evident, measurable observations such as vital signs, odors, redness, hostile behaviors, and findings from lab tests or medical imaging. It can be seen, heard, felt, or smelled and obtained by observation or physical exam.
  • Includes physical characteristics, body functions, appearance, behavior, measurements, and results of lab tests.

Pain Assessment

• Pain is a subjective, unpleasant sensory and emotional experience.
• Pain assessments should be completed every 4 hours, and vital signs should be taken.
• Pain assessment on admission includes: previous pain experiences, effects on the patient, methods used (helpful or not), a history of substance abuse, and how the patient describes/shows pain. Patient's medications (including OTC and herbal remedies) should also be considered. Establish an acceptable pain level with the patient.

Nurse Responsibility

• Upon admission, all patients will be assessed for pain using one of the following scales:
  • Numeric Pain Intensity Scale
  • Wong-Baker Faces Pain Scale
  • FLACC (Faces, Legs, Activity, Cries, CONSOL ability)
  • CRIES (Crying, Requires oxygen, Increased Vital Signs, Expression, Sleeplessness)
  • CPOT (Critical Care Pain Observation Tool)

Pain Scales

• Numeric Pain Intensity Scale: Commonly used for hospitalized and nursing home patients, even those with mild to moderate dementia. The scale asks the person to rate their pain on a scale of 0-10, with 0 being no pain and 10 being the worst possible pain.
• Wong-Baker FACES Pain Scale: Developed by Donna Wong and Connie Baker, it's for children 3 years or older. A series of faces ranging from a happy face (0) to a crying face (10) helps the patient choose the face that best describes their pain.
• FLACC Scale: (Faces, Legs, Activity, Cries, CONSOL ability) Appropriate for children age 2 months to 7 years (not for those with developmental delays). Each category is scored 0-2, allowing a score of 0-10.
• CRIES Scale: Recommended for infants under 6 months of age. Scored 0-2 for five categories: Crying, Requires Oxygen, Increased Vital Signs, Expression, and Sleeplessness. Gives a total score of 0-10.
• CPOT: Critical Care Pain Observation Tool. For non-verbal or critically ill patients. Scores four categories of Facial expressions, Body movements, Compliance with ventilator, and Muscle tension on a 0-2 scale. Gives a total score of 0-8.

Source of Data Collection

• Primary Source: Data about the patient is directly collected from the patient themselves, using an interview and physical examination.

• Secondary source: If needed, data is gathered from family members.

Additional Pain Assessment Information

• Components of pain assessment:         - Location: Precise or general location, diffuses, etc. Diagram can be helpful.         - Intensity: Pain's severity description translated into objective scale measure (Numeric, Wong-Baker, FLACC, CRIES, or CPOT).         - Quality: Describe using words like stabbing, throbbing, cramping, vise-like, burning, superficial, etc.         - Radiation: If pain is spreading from the initial location.         - Duration: How long the pain has lasted.

This quiz covers the essential concepts of health assessment, focusing on both subjective and objective data collection methods. It emphasizes the importance of systematic and continuous data gathering in planning patient-centered care. Test your understanding of the different types of data collected during health assessments.