Assessing Pain And Nutritional Status PDF

ASSESSING PAIN THE 5TH VITAL SIGNS PAIN DESCRIBES UNCOMFORTABLE SENSATIONS IN THE BODY. Pain can range from annoying to debilitating. It may feel like a SHARP STAB or DULL ACHE. It may also be described as THROBBING, PINCHING, STINGING, BURNING, OR SORE. PAIN Pain is whatever the per...

ASSESSING PAIN THE 5TH VITAL SIGNS PAIN DESCRIBES UNCOMFORTABLE SENSATIONS IN THE BODY. Pain can range from annoying to debilitating. It may feel like a SHARP STAB or DULL ACHE. It may also be described as THROBBING, PINCHING, STINGING, BURNING, OR SORE. PAIN Pain is whatever the person says it is. ( McCaffery and Pasero 1999) PATHOPHYSIOLOGY The pathophysiologic pain phenomena are associated with the Central Nervous System and Peripheral Nervous Systems. PATHOPHYSIOLOGY NOCICEPTORS A sensory receptors for pain stimuli. Located at peripheral ends of both myelinated nerve endings of type A fibers or unmyelinated type C fibers. PATHOPHYSIOLOGY NOCICEPTORS Distributed in the body, skin, subcutaneous tissue, skeletal muscle, joints, peritoneal surfaces, pleural membranes, dura mater, and blood vessel walls. PATHOPHYSIOLOGY NOCICEPTOR THREE TYPES OF NOCICEPTORS STIMULATED BY A STIMULI: A. Mechanosensitive Nociceptors (of A-delta fibers) B. Temperature-sensitive (Thermosensitive) Nociceptors (of A-delta fibers) C. Polymodal Nociceptors (of C fibers) PATHOPHYSIOLOGY NOCICEPTORS A-delta primary afferent fibers Transmit fast pain to the spinal cord within 0.1 second, which is felt as a pricking, sharp, or electric- quality sensation and usually is caused by mechanical or thermal stimuli PATHOPHYSIOLOGY C fibers Transmit slow pain within 1 second, which is felt as burning, throbbing, or aching and is caused by mechanical, thermal, or chemical stimuli, usually resulting in tissue damage. PATHOPHYSIOLOGY FOUR PROCESS OF NOCICEPTION TRANSDUCTION TRANSMISSION PERCEPTION MODULATION PATHOPHYSIOLOGY TRANSDUCTION Begins when a mechanical, thermal, or chemical stimulus results in tissue injury or damage stimulating the nociceptors, which are the primary afferent nerves for receiving painful stimuli PATHOPHYSIOLOGY TRANSMISSION It is initiated by an inflammatory process, resulting in the conduction of an impulse in the primary afferent neurons to the dorsal horn of the spinal cord. PATHOPHYSIOLOGY PERCEPTION Neural process of encoding and processing noxious stimuli PATHOPHYSIOLOGY Hypothalamus And Limbic System - Responsible for the emotional aspect of pain perception. Frontal Cortex – For rational interpretation and response to pain. PATHOPHYSIOLOGY Modulation Changes or inhibits the pain message relay in the spinal cord. CLASSIFICATION OF PAIN ACUTE PAIN - Developing suddenly and lasting for a short period CHRONIC PAIN - With ongoing sensations that last or return repeatedly over several months or years. TYPES OF PAIN Nociceptive pain Caused by tissue damage. For example, cuts, burns, bruises, or fractures. It may also result from certain health conditions that cause tissue inflammation and damage, such as arthritis, TYPES OF PAIN Neuropathic pain - Results from nerve damage, which may be caused by a variety of injuries and illnesses. TYPES OF PAIN FUNCTIONAL PAIN - is pain that’s caused by no obvious injury or damage to your body. - It tends to be chronic, although acute functional pain may also develop. TYPES OF PAIN CANCER PAIN Often due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration TYPES OF PAIN Cutaneous pain (skin or subcutaneous tissue) Visceral pain (abdominal cavity, thorax, cranium) Deep somatic pain (ligaments, tendons, bones, blood vessels, nerves) TYPES OF PAIN RADIATING PAIN - Perceived at the site of the pain stimuli - perceived both at the source and extending to other tissues TYPES OF PAIN REFERRED PAIN - Perceived in body areas away from the pain source. TYPES OF PAIN PSYCHOLOGICAL PAIN - Emotional pain or mental pain TYPES OF PAIN Psychosomatic/Psycho genic - The process of somatization - When psychological pain becomes physical TYPES OF PAIN PSYCHOSOMATIC SOMATIZATION - involves transferring or converting uncomfortable feelings into physical symptoms TYPES OF PAIN INFLAMMATORY PAIN - Is a common caused by the release of pro-inflammatory cytokines after tissue damage or inflammation PAIN LOCALIZE PAIN Affecting a specific body part GENERALIZED Overall body aches associated with the flu CATEGORIES OF PAIN DURATION – Acute Vs. Chronic LOCATION – Central Vs. Peripheral PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND ASSESSMENT DEVELOPMENTAL LEVEL CULTURAL LEVEL PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND ASSESSMENT DEVELOPMENTAL LEVEL PEDIATRIC (neonate to later childhood) and GERIATRIC age groups, have characteristics that make pain assessment more difficult PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND ASSESSMENT DEVELOPMENTAL LEVEL The results of undertreated pain in any client can be profound, resulting in both physical and psychological problems that can be avoided if pain is assessed and treated properly PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND ASSESSMENT DEVELOPMENTAL LEVEL Undertreated pain in children can lead to chronic pain conditions when they become adults. PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND ASSESSMENT QUESTT (Baker and Wong, 1978) Question the child Use pain rating scale Evaluate behavior and Physiologic changes Secure parents involvement Take cause of pain into account Take action and evaluate the results PAIN PERCEPTION AND ASSESSMENT TOOLS AND BEHAVIORS FOR ASSESSING PAIN IN OLDER ADULTS WITH AND WITHOUT COGNITIVE IMPAIRMENT (Banicek, 2010)  Without Cognitive Impairment Visual Analog Scale (VAS) Numerical Pain Intensity Scale Categorical Rating Scale - None (0), Mild (1), Moderate (2), Severe (3) PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND ASSESSMENT TOOLS AND BEHAVIORS FOR ASSESSING PAIN IN OLDER ADULTS WITH AND WITHOUT COGNITIVE IMPAIRMENT (Banicek, 2010)  With Cognitive Impairment Observe Behaviors that may Indicate Pain: FACIAL EXPRESSIONS VOCALIZATION CHANGE IN BODY LANGUAGE BEHAVIORAL CHANGE PHYSIOLOGIC CHANGE PHYSICAL CHANGE FACIAL PAIN SCALE COLLECTING SUBJECTIVE DATA FOR PAIN CHARACTERISTIC ONSET LOCATION DURATION SEVERITY PATTERN ASSOCIATED FACTOR COLLECTING SUBJECTIVE DATA FOR PAIN EFFECTS OF PAIN ON ADL COPING STRATEGIES EMOTIONAL RESPONSES COLLECTING SUBJECTIVE DATA FOR PAIN BARRIERS OF PAIN ASSESSMENT  BASED ON BELIEF  BASED ON PHYSICAL CONDITIONS  BASED ON HEALTHCARE PROVIDERS’ BELIEFS COLLECTING SUBJECTIVE DATA FOR PAIN BARRIERS OF PAIN ASSESSMENT BASED ON PHYSICAL CONDITIONS Unable To Self Report Pain Use Behavioral Pain Scale (BPS) COLLECTING OBJECTIVE DATA FOR PAIN KEY FACTORS IN PHYSICAL ASSESSMENT Choose an assessment tool that is reliable and valid to the client’s culture. Explain to the client the purpose of rating the intensity of pain. Ensure the client’s privacy and confidentiality. COLLECTING OBJECTIVE DATA FOR PAIN KEY FACTORS IN PHYSICAL ASSESSMENT Respect the client’s behavior towards pain and the terms used to express it. Understand that different cultures express pain differently and maintain different pain thresholds and expectations. SELECTED NURSING DIAGNOSES Health Promotion Diagnoses Readiness for enhanced spiritual well-being related to coping with prolonged physical pain Readiness for enhanced comfort SELECTED NURSING DIAGNOSES Risk Diagnoses Risk for activity intolerance related to chronic pain and immobility Risk for constipation related to nonsteroidal anti-inflammatory agents or opiate intake or poor eating habits Risk for spiritual distress related to anxiety, pain, life change, and chronic illness Risk for powerlessness related to chronic pain, health care environment, pain treatment–related regimen SELECTED NURSING DIAGNOSES Actual Diagnoses Acute pain related to injury agents (biologic, chemical, physical, or psychological) Chronic pain related to chronic inflammatory process of rheumatoid arthritis Ineffective breathing pattern related to abdominal pain and anxiety Disturbed energy field related to pain and anxiety Fatigue related to stress of handling chronic pain Impaired physical mobility related to chronic pain Bathing/hygiene self-care deficit related to severe pain (specify) ASSESSING NUTRITIONAL STATUS NUTRITIO A N Process by which substances in food are transformed into body tissue and provide energy for the full range of physical and mental activities that make up human life. Carbohydrates, proteins, fats, vitamins, minerals, and water. Optimal Nutritional Status - Most beneficial nutrition status - Requires a balance of nutrient intake to meet daily metabolic demands. MALNUTRITION UNDERNUTRITION OVERNUTRTION UNDERNUTRITION RESULT FROM INADEQUATE NUTRIENT INTAKE OR NUTRITIONAL RESERVES BEING DEPLETED UNDERNUTRITION RISK FACTOR  Lower socioeconomic status  Lifestyle  Poor food choices  Chronic dieting  Chronic diseases  Dental and other factors  Limited access to sufficient food  Disorders whereby food is self-limited or refused  Illness or trauma OVERNUTRITION Increased caloric consumption, especially of food high in fat and sugar. Occurs when the intake of nutrients exceeds the body’s metabolic needs to maintain normal growth, development, and metabolism. A person over 10% of the ideal body weight DEHYDRATION Can have a seriously damaging effect on body cells and the execution of body functions. COLLECTING SUBJECTIVE DATA COLLECTING SUBJECTIVE DATA COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION Equipment Balance beam scale with height attachment Metric measuring tape Marking pencil Skin fold calipers ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS General Status/Appearance Observe client’s Alert, oriented, well general status and developed for appearance. age, ideal weight, intact skin, normal skin tone, texture, appropriately dressed for season.  ABNORMAL FINDINGS Body System or Region Sign or Symptom Implications General Weakness and Anemia or fatigue electrolyte Weight loss imbalance Decreased calorie intake, increased calorie use, or inadequate nutrient intake or absorption Skin, Hair, And Dry, flaky skin Vitamin A, vitamin Nails Dry skin with poor B-complex, or turgor linoleic acid Rough, scaly skin deficiency with bumps Dehydration Petechiae or Vitamin A ecchymoses deficiency Sore that will not Vitamin C or K heal deficiency Body System or Region Sign or Symptom Implications Eyes Night blindness; Vitamin A deficiency corneal swelling, softening, or dryness; Bitot’s spots (gray triangular patches on the Riboflavin deficiency conjunctiva) Red conjunctiva Throat And Mouth Cracks at the Riboflavin or corner of mouth niacin deficiency Magenta Riboflavin tongue deficiency Beefy, red Vitamin B12 tongue deficiency Soft, spongy, Vitamin C bleeding deficiency Iodine deficiency Body System or Region Sign or Symptom Implications Cardiovascular Edema Protein Tachycardia, deficiency hypotension Fluid volume deficit Gastrointestinal Ascites Protein deficiency Musculoskeletal Bone pain and bow Vitamin D or calcium leg deficiency Muscle wasting Protein, carbohydrate, and fat deficiency Neurologic Altered mental status Dehydration and Paresthesia thiamine or vitamin B12 deficiency Vitamin B12, pyridoxine, or thiamine deficiency ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Body Build Observe body build as well as A wide variety of body types A lack of subcutaneous fat muscle fall within a with prominent mass and fat distribution. normal range—from fat and bones is seen in the muscle. In general, undernourished. the normal body is Abdominal ascites is seen in proportional. Bilateral starvation and muscles are firm and well liver disease. Abundant fatty developed. tissue is noted There is equal distribution of in obesity. fat with some subcutaneous fat. Body parts are intact and appear equal without obvious deformities.  ECTOMORPH TRAITS SMALL “DELICATE FRAME AND BONE STRUCTURE FLAT CHEST SMALL SHOULDER THIN LEAN MUSCLE MASS FINDS IT HARD TO GAIN WEIGHT FAST METABOLISM  MESOMORPH TRAITS  ATHLETIC  GENERALLY HARD BODY  WELL DEFINED MUSCLES  RECTANGULAR-SHAPED BODY  STRONG  GAINS MUSCLE EASILY  GAINS FAT MORE THAN ECTOPHORM  ENDOMORPH TRAITS  SOFT AND ROUND BODY  GAINS MUSCLE AND FAT VERY EASILY  IS GENERALLY SHORT  STOCKY BUILD  ROUND PHYSIQUE  FINDS IT HARD TO LOSE FAT  SLOW METABOLISM  MUSCLE NOT SO WELL DEFINED ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Anthropometric Measurements Measure Height Height is within Extreme shortness is range for age, and seen in achondroplastic ethnic dwarfism and Turner’s and genetic syndrome. Extreme heritage. tallness is seen in gigantism (excessive secretion of growth hormone) and in Marfan’s syndrome. ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Anthropometric Measurements Measure Weight Normal weight based Underweight on BMI Overweight Obese  BODY MASS INDEX Weight in kg = BMI Height in meters BODY WEIGHT CATEGORY CHILDREN AND ADULTS ADOLECENTS (AGE 2-19) (BMI) (BMI for Age Percentile Range UNDER WEIGHT LESS THAN 5TH PERCENTILE LESS THAN 18.5 Kg/m² NORMAL WEIGHT 5TH PERCENTILE TO LESS 18.5-24.9 kg/m² THAN 85TH PERCENTILE OVERWEIGHT 85TH TO LESS THAN THE 95TH 25.0-29.9 kg/m² PERCENTILE OBESE EQUAL TO OR GREATER 30.0 kg/m² and greater THAN THE 95TH PERCENTILE ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Anthropometric Measurements Determine waist to hip Females: less than or Females: Greater than ratio equal to 0.80cm or equal to 0.80cm Male: less than or Male: Greater than or equal to 0.90cm equal to 0.90cm Waist circumference = Waist to hip ratio Hip circumference ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Anthropometric Measurements Measure mid-arm Measurements less than 90% circumference (MAC) of the evaluates skeletal muscle standard reference are in the mass and fat stores. category of moderately malnourished. Less than 60% of the standard reference indicates severe malnourishment.  MIDARM CIRCUMFERENCE STANDARD REFERENCE Adult MAC (cm) Standard Reference 90% of Standard 60% of Standard Reference— Reference— Moderately Severely Malnourished Malnourished MEN 29.3 26.3 17.6 WOMEN 28.5 25.7 17.1 Have the client fully extend and dangle the nondominant arm freely next to the body. Locate the arm’s midpoint (halfway between the top of the acromion process and the olecranon process) ARMS MIDPOINT MIDARM CIRCUMFERENCE ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Anthropometric Measurements Measure triceps skin fold REFER TO Measurements less than 90% thickness of the (TSF).. (TSF)STANDARD standard reference indicate REFERENCE a loss of fat stores and place the client in the moderately malnourished category. Less than 60% of the standard reference indicates severe malnourishment. Measurements greater than 130% of the standard indicate obesity  TRICEPS SKINFOLDNTHICKNESS (TSF)STANDARD REFERENCE Adult TSF (mm) Standard Reference 90% of Standard 60% of Standard Reference— Reference— Moderately Severely Malnourished Malnourished MEN 13.5 11.3 7.5 WOMEN 16.5 14.9 9.9 ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS Assessing Hydration Measure intake and output I&O are closely balanced Imbalances in either direction (I&O) in inpatient over 72 hours when suggest settings. insensible loss is included. impaired organ function and fluid overload or inability to compensate for losses, resulting in dehydration. HEALTH PROMOTION DIAGNOSES Readiness for Enhanced Self-health management related to desire and request to learn more about testing blood glucose level Readiness for Enhanced Fluid Balance related to a desire for information pertaining to a need for increased fluids RISK DIAGNOSES Risk for Deficient Fluid Volume related to impending dehydration secondary to nausea, vomiting, and voiding large quantities of urine Risk for Imbalanced Nutrition: More Than Body Requirements related to increasing sedentary lifestyle and decreasing metabolic demands ACTUAL DIAGNOSES Disturbed Body Image related to recent weight loss Hopelessness related to inability to adhere to prescribed diet Imbalanced Nutrition: Less Than Body Requirements related to nausea, vomiting, and lack of appetite associated malignant or cancerous cachexia Deficient Fluid Volume related to nausea and vomiting SELECTED COLLABORATIVE PROBLEMS RC: Hypertension RC: Hyperlipidemia RC: Ketoacidosis RC: Hyperglycemia RC: Diabetes mellitus type 2 RC: Morbid obesity SELECTED COLLABORATIVE PROBLEMS RC: Bulimia; anorexia nervosa RC: Short bowel syndrome RC: Lactose intolerance RC: Iron deficiency anemia (any nutritional deficiency or allergy/intolerance) ABNORMAL FINDINGS OBESITY  RESPIRATORY DISEASE  OBSTRUCTIVE SLEEP APNEA  SURGICAL COMPLICATION  STROKE  GALLBLADDER DISEASE  DIABETES MELLITUS DISTRIBUTION OF ADIPOSE TISSUE ABNORMAL FINDINGS KWASHIORKOR DISEASE ABNORMAL FINDINGS MARASMUS VITAMIN A DEFFICIENCY BITOT SPOT IN THE TEMPORAL INTERPALPEBRAL FISSURE CONJUNCTIVAL AND CORNEAL XEROSIS KERATOMLACIA RIBOFLAVIN DEFFICIENCY CHEILOSIS AND ANGULAR STOMATITIS MAGENTA TONGUE FLUOROSIS ZINC DEFFICIENCY WHITE SPOTS ON THE NAILS SMOOTH TONGUE