Data and Pain Assessment PDF

Collection of Data and Pain Assessment Health assessment Is systematic method of collecting and analyzing data for purpose of planning patient-centered care. Physical examination It is the techniques used to collect objective data about the body from head to toes". Collecting Data: Is the pr...

Collection of Data and Pain Assessment Health assessment Is systematic method of collecting and analyzing data for purpose of planning patient-centered care. Physical examination It is the techniques used to collect objective data about the body from head to toes". Collecting Data: Is the process of collecting information about a client’s health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a client‘s changing health status. Types of Collected Data: 1. Subjective Data (Stated) 2. Objective Data (Observed) Subjective Data (Stated) It referred to as symptoms or covert data. It is the verbal statements stated to the assessor by the patient through interview. It can be described or verified only by that person. ❖ Subjective Data It includes: 1. Biographical data 2. Reasons for seeking health care 3. History of present health concerns 4. Past health history 5. Family health history 6. Lifestyle and health practices profile 7. Developmental level Objective Data (Observed) 1. It referred to as signs or overt data. 2. It is evident, measurable and observations such as vital signs, odors, redness of a wound, hostile behavior, and laboratory and medical imaging findings. 3. It can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.  Objective data include: 1. Physical characteristics 2. Body functions 3. Appearance 4. Behavior 5. Measurement 6. Results of laboratory testing Subjective Data What the patient tells you. The history, from chief complaint through Review of Systems. Objective Data What you detect on the examination. All physical examination findings.  Source of data collection 1. Primary source: Data are directly collected from the client using interview and physical examination. 2. Secondary source: Data are collection from client‘s family members. Pain Assessment Is unpleasant sensory and emotional experience, because pain is always subjective. Pain assessment shall be completed at minimum of every 4 hours with vital signs  Nurse Responsibility ✓ Upon admission, all patients will be assessed for pain: Previous and ongoing instances of pain and its effects on the patient. Previously used methods for pain control that the patient either found helpful or unhelpful. Any history of substance abuse. Ways the patient describes or shows pain. patient’s medications use including over-the-counter medications and herbal remedies. The patient and nurse will establish an acceptable pain level using one of the following pain scales: 1. Numeric Pain Intensity Scale. 2. Wong-Baker Faces Pain Scale. 3. FLACC (Faces, Legs, Activity, Cries, CONSOL ability). 4. CRIES (Crying, Requires oxygen, Increased Vital Signs, Expression, Sleeplessness). 5. CPOT (Critical Care Pain Observation Tool).  Pain Assessment : Pain Scales I. Numeric Pain Intensity Scale is commonly and successfully used with hospitalized and nursing home patients, even those with mild and moderate dementia. This scale asks the person in pain to assign a number, from zero to ten, to the severity of their pain, zero being no pain and ten being the worst possible pain they can imagine.  2. Wong-Baker FACES Pain Scale developed by Donna Wong and Connie Baker. Use for children ages 3 or older. the scale shows a series of faces ranging from a happy face at 0, “No hurt” to a crying face at 10 “Hurts worst”.the patient chooses the face that best describes his or her own pain.  3. FLACC (Faces, Legs, Activity, Cries, CONSOL ability) Recommended for children between 2 months to 7 years of age (not valid for children with developmental delay) Each category is scored from 0-2: (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability. The score will be 0-10.  Pain Assessemt : Scales – cont’d 4.. CRIES (Crying, Requires Oxygen, Increased Vital signs,Expression,Sleeplessness) Recommended for infants less than 6 months of age Each of the five categories is scored from 0-2: (C) Crying; (R) Requires oxygen; (I) Increased vital signs; (E) Expression; (S) Sleeplessness. The total score will be 0-10.CRIES  Pain Assessment : Scales – cont’d 5. CPOT (Critical Care Pain Observation Tool) Recommended for non-verbal patients or critically ill patients Each of the four categories is scored from 0-2: Facial expressions; Body movements; Compliance with the ventilator; muscle tension. The total score will be 0-8.