How does it travel?
Spreads to another area
What is
Radiating Pain?
Severe abdominal cramping
What is
Colicky?
Patient complains of pain in his back that is 8/10? What is your first action?
Can you describe the pain?
Assess pulse deficit
What is obtain apical pulse at the same time another nurse obtains the radial pulse?
What is assess apical and radial pulse at same time?
Heart rate
What is 60-100?
Two parts of Behavior and mental staus
What are
Level of consciousness: alert and oriented
Behavior-calm, agitated, cooperative, restless, eye contact
Name signs of Respiratory distress that would be obvious in the general survey
What are- cyanosis, use of accessory muscles, SOB, tachypnea
O
What is onset
P
What is Provocation and Palliates?
What causes the pain? What makes it worse? What makes it better
I listen to high pitched sounds
What is the diaphragm?
Felt in an area away from the actual source of pain.
What is
Referred Pain?
Sharp pain such as associated with a skin laceration
What is
Cutaneous Pain?
You notice indications of respiratory distress. What is the nurse's first action?
What is assess vital signs especially respiratory rate and oxygen saturation?
Assess the pain in someone with the inability to communicate
What are
Assess for non-verbal S/S of pain: restlessness, facial grimacing, guarding
Vital signs S/S of pain: increased BP, HR, and RR
Respiratory rate
What is 12-20?
Three parts of Mobility
What are:
Gait-steady. staggering, limping, holding o to furniture or wall, use of assistive devices
Posture
Range of Motion;
Name signs of Cardiac distress that would be obvious in the general survey
What is clutching/kneading chest, rubbing arm, cyanosis
A
What is Aggravating or Alleviating factors?
What makes the makes the pain better?
What makes the makes the pain Worse?
Q
What is Quality?
What does the pain feel like?
I listen to low pitched sounds
What is the bell?
Sudden, sharp pain that is short in duration
What is
Acute Pain?
Pins and Needles pain in leg and or foot
What is
Neuropathic Pain?
Client has dizziness when changing positions. What is your next action?
What is assess blood pressure sitting and standing?
Questions to ask related to recent activities before taking a blood pressure?
What is
Have you smoked, exercised, or had caffeine within the last 30 minutes?
BP
What is Systolic less than 120
and
Diastolic less than 80
Name the three areas of the general survey that are assessment findings. (Not just observation)
What are
Height and Weight
Vitals Signs
Name signs of Gastrointestinal distress that would be obvious in the general survey
What is holding or rubbing stomach, guarding abdomen, vomiting
C
What is Character?
What does the pain feel like?
R
What is Radiation and Region?
Where is it located? Is it confined to one place? Does it radiate, if so where?
Ear pieces should face me when placed in the earss
What is the nose?
Pain that lasts more than 3 months and may be described as disabling.
Pain that lasts more than 3 months and may be described as disabling.
Another name for musculoskeletal pain
What is
Somatic pain?
Client is complaining of pain and chills after surgery. What is your first assessment?
What is vital signs?
Questions to ask before taking an oral temperature?
What is
Have you smoked, eaten or drank anything in the last 15-30 minutes?
Oral Temperature
What is 97.5 to 99.5 ?
During the Health History interview, your client states that they are Jewish. What is your first question to demonstrate cultural inclusivity and diversity?
What is ask if there are cultural or religious practices that may affect their care?
Name signs of general distress that would be obvious in the general survey. (do not include Respiratory, Cardiac, or GI)
What is fatigue, muscle weakness, decreased endurance, appearing older than stated age,
L
What is Location/Radiation?
Where is the pain located? Does the pain radiate?
S
What is severity?
Can you rate your pain on a scale from 1-10, with 0 being no pain and 10 being the worse pain possible.
How does it affect your daily activity?
Listening with the stethoscope during an assessment is called this
What is auscultation?
Severe, unrelenting pain that does not respond to pain relief measures
What is
Intractable Pain?
Pain that is felt even after the affected body part has been removed
What is
Phantom Limb Pain?
Client has respirations of 8. What is your first action?
What is assess oxygen saturation?
You are taking a BP in the upper arm. Name three Physical assessments that you need to assess before continuing?
(Not missing an arm 🤪)
What is a mastectomy, location of IV, or rash/sore on arm?
Oxygen Saturation
What is
Greater than (>) 95%
Four major components of physical appearance
What are
Health-do they appear healthy, ill, or chronically ill?
Age: Do they appear their age?
Hygiene- good hygiene, any odors, dressed appropriately for the weather, breath
Body structure- Build, size, symmetry
Name signs of pain that would be obvious in the general survey
What is
Crying, furrowed brow, restlessness, clutching or rubbing a part of the body, sweating
T
What is Treatment?
How do you relieve the pain? What medications do you take? What non-pharmacologic? Who his treating your pain?
T
What is timing or temporal?
When did it start? Is it present all the time? Are you ever pain free? How long does it last? Does movement cause pain?
Do not use me when holding a stethoscope in place
What is the thumb?