Chapter 1: Evidence-Based Assessment (p 1-9)

 Assessment – collection of data about the individual’s health state

o Subjective Data – what the person says about himself or herself during history taking
o Objective Data – what you as the health professional observe by inspecting, percussing,
palpating, and auscultating during the physical examination
o Diagnostic Reasoning – process of analyzing health data and drawing conclusions to identify
diagnoses
 Hypothetic-Deductive Process
 Attending to initially available cues
 Formulating diagnostic hypotheses
 Gathering data relative to the tentative hypotheses
 Evaluating each hypothesis with the new data collected, thus arriving at a final
diagnosis
 Cue – piece of information, a sign or symptom, or a piece of laboratory or imaging data
 Hypothesis – tentative explanation for a cue or a set of cues that can be used as a basis for
further investigation
o Once data collection is complete, develop a preliminary list of significant signs and symptoms
for all patient health needs
o Cluster the assessment data that appear to be causal or associated
o Validate the data collected to make sure they are accurate
 As you validate your information, look for gaps in data collection
 Identifying missing information is an essential critical-thinking skill
 How you validate your data depends on experience
 If unsure about BP, validate by repeating it yourself, or ask another nurse to
validate the findings
 Eliminate any extraneous variables that could influence BP results such as recent
activity or anxiety over admission
 Nursing Process
o Assessment
 Collect data
 Use evidence-based assessment techniques
 Document relevant data
o Diagnosis
 Compare clinical findings with normal and abnormal variation and developmental events
 Interpret data
 Validate diagnoses
 Document diagnoses
o Outcome Identification
 Identify expected outcomes
 Individualize to the person
 Identify expected culturally appropriate outcomes
 Establish realistic and measurable outcomes
 Develop a timeline
o Planning
 Establish priorities
 Develop outcomes
 Set timelines for outcomes
 Identify interventions

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  Integrate evidence-based trends and research
 Document plan or care
o Implementation
 Implement in a safe and timely manner
 Use evidence-based interventions
 Collaborate with colleagues
 Use community resources
 Coordinate care delivery
 Provide health teaching and health promotion
 Document implementation and any modification
o Evaluation
 Progress toward outcomes
 Conduct systematic, ongoing, criterion-based evaluation
 Include patient and significant others
 Use ongoing assessment to revise diagnoses, outcomes, plan
 Disseminate results to patient and family
 Remember to approach problems in a nonjudgmental way and to avoid making assumptions
 Immediate Priorities
o First-Level Priority Problems
o Second-Level Priority Problems
o Third-Level Priority Problems
 Evidence-Based Practice (EBP)
o Important to question tradition when no compelling research evidence exists to support it
 Types of Patient Data
o Complete (Total Health)
 Includes a complete health history and a full physical examination
 Describes current and past health state and forms a baseline against which all future
changes can be measured
o Focused or Problem-Centered
 Concerns mainly one problem, one cue complex, or one body system
o Follow-Up
 Used to follow up both short-term and chronic health problems
 Holistic Health – views the mind, body, and spirit as interdependent and functioning as a whole within
the environment

Chapter 2: Cultural Assessment (p 11-22)

 Cultural Assessment – integral part of forming a full database of information about each patient
 Social Determinants of Health (SDOH)
o The five social determinants of health are interconnected and affect a person’s health from
preconception to death

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  Culture – complex phenomenon that includes attitudes, beliefs, self-definitions, norms, roles, and values
o A person’s culture defines health and illness, identifies when treatment is needed and which
treatments are acceptable, and informs a person of how symptoms are expressed and which
symptoms are important
 Ethnicity – refers to a social group that may possess shared traits, such as common geographic origin,
migratory status, religion, language, values, traditions or symbols, and food preferences
 Spirituality – broader term focused on a connection to something larger than oneself and a belief in
transcendence
 Religion – refers to an organized system of beliefs concerning the cause, nature, and purpose of the
universe, as well as the attendance of regular services
 Completing a Cultural Assessment
o Cultural Self-Assessment
 Cultural Sensibility
o Cultural Assessment
o Spiritual Assessment
 FICA Spiritual History Tool
 Faith
 Importance/Influence
 Community
 Address/Action

Chapter 3: The Interview (p 23-44)

 Data Collection
o Subjective Data – what the person says about himself or herself
o Objective Data – what you obtain through physical examination
 Successful Interviews
 Process of Communication
o Sending
 Verbal Communication
 Nonverbal Communication
o Receiving
 Interpretation of Verbal and Nonverbal
o Internal Factors
 Liking Others
 Empathy
 Active Listening
 Self-Awareness
o External Factors
 Ensure Privacy
 Refuse Interruptions
 Physical Environment
 Dress
 Note-Taking
 Electronic Health Record (EHR)
 Phases of the Interview
o Introduction
 Address the person by his or her surname
 Indicate the reason for the interview
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  Prepare patient for what to expect
o Working Phase – data-gathering phase
 Open-Ended Questions – asks for narrative information; states the topic to be discussed
but only in general terms; unbiased
 Use it to begin the interview, to introduce a new section of questions, and
whenever the person introduces a new topic
 As the person answers, make eye contact and actively listen
 Closed or Direct Questions – asks for specific information
 Help elicit specific information and are useful to fill in any details that were
initially left out after the person’s opening narrative
 Verbal Responses
 Facilitation
o Encourages client to say more and shows person you are interested
 Silence
o Communicate that the client has time to think
 Reflection
 Empathy
o Allows person to feel accepted and strengthens rapport
 Clarification
o Summarizes person’s words, simplify the statement, and ensure that you
are on the right track
 Confrontation
 Interpretation
 Explanation
 Summary
 Traps of Interviewing
 Providing false assurance or reassurance
 Giving unwanted advice
 Using authority
 Using avoidance language
 Distancing
 Using professional jargon
 Using leading or biased questions
 Talking too much
 Interrupting
 Using “why” questions
 Nonverbal Skills
 Physical Appearance
 Posture
 Gestures
 Facial Expression
 Eye Contact
 Voice
 Touch
o Closing
 Give final opportunity for self-expression
 Make a closing statement that indicates that the end of the interview is imminent

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  Summary – final statement of what you and the client agree the health state to be
 Should include positive health aspects, any health problems that have been
identified, any plans for action, and an explanation of the subsequent physical
examination
 Thank the client for the time spent and their cooperation
 Interviewing People with Special Needs
o Hearing-Impaired People
 Must use cues to recognize potential hearing loss, such as client staring at your mouth,
not answering unless looking at you, speaking in an unusually loud voice, or frequently
requesting that you repeat a question
 May require a sign language interpreter
 Speak slowly and supplement your voice with appropriate hand gestures
o Acutely Ill People
 Emergent situations require combining the interview with the physical examination
 Subjective information is crucial
o People Under the Influence of Street Drugs or Alcohol
 Client’s behavior depends on which drugs were consumed
 Alcohol, benzodiazepines, and the opioids are CNS depressants that slow brain
activity and impair judgement, memory, intellectual performance, and motor
coordination
 Stimulants of the CNS can cause an intense high, agitation, and paranoid behavior
 Hallucinogens cause bizarre, inappropriate, sometimes violent behavior
accompanied by superhuman strength and insensitivity to pain
 Ask simple and direct questions
 Nonthreatening manner and questions
 Avoid confrontation and displaying any scolding or disgust
 Top priority is to find out the time of the person’s last drink or drug, how much he or she
took, and the name of each drug that was taken
o Personal Questions
 You do not need to answer questions about your personal life or opinions
o Sexually Aggressive People
 Make it clear that you are a health professional who can best care for the person by
maintaining a professional relationship
 Important to communicate that you cannot tolerate sexual advances, but also
communicate that you accept the person and understand his or her need to be self-
assertive
o Crying
 Crying is a big relief to a person
 Do not go on to a new topic; it is important that you allow the person to cry and express
his or her feelings fully before you move on
 Wait until the crying subsides to talk and reassure the crying client that he or she does not
need to be embarrassed and that you are there to listen
 If the client looks as if he or she is on the verge of tears but is trying hard to suppress
them, acknowledge the expression (“you look sad”)
 Person may cry, but will be relieved
o Anger
 Don’t take the anger personally
 Person is showing aggression as a response to his or her own feelings of anxiety or
helplessness
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  Ask about the anger and hear the person out
 Deal with the angry feelings before you ask anything else
o Threats of violence
 Over 70% of nurses report physical or verbal abuse in the workplace
 Identify red-flag behaviors of a potentially disruptive person
 Include fist clenching, pacing, a vacant stare, confusion, statements out of touch
with reality or that do not make sense, a history of recent drug use, or a recent
history of intense bereavement (loss of partner, loss of job)
 If you sense any suspicious or threatening behavior, act immediately to defuse the
situation, or obtain additional support from others
 Do not raise your own voice or try to argue with the threatening person
o Anxiety
 Nearly all sick people have some anxiety; it is a normal response to being sick
 Appearing unhurried and taking the time to listen to all of the client’s concerns can help
defuse some anxiety
 Using an Interpreter
 Health Literacy – the ability to understand instructions, navigate the health care system, and
communicate concerns with the health care provider
 Communicating With Other Professionals
o Interprofessional Communication
o Standardized Communication
 SBAR
 Situation
 Background
 Assessment
 Recommendation

Chapter 4: The Complete Health History (p 45-56)

 Subjective Data – what the person says about himself or herself
 Health History – provides a complete picture of the person’s past and present health
o Biographic Data
 Name, address, and phone number; age and date of birth; birthplace; gender; relationship
status; race; ethnic origin; and occupation
 Record the person’s primary language
o Source of History
o Reason for Seeking Care
 Symptom – a subjective sensation that the person feels from the disorder
 Sign – an objective abnormality that you as the examiner could detect on physical
examination or through diagnostic testing
 Try to record whatever the person says is the reason for seeking care, enclose it in
quotation marks to indicate the person’s exact works, and record a time frame
o Present Health or History of Present Illness
 For the well person, a short statement about the general state of health
 For the ill person, a chronologic record of the reason for seeking care from the time the
symptom first started until now
 Summary of Symptoms
 Location
 Character or Quality

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  Quantity or Severity
 Timing (Onset, Duration, Frequency)
 Setting
 Aggravating or Relieving Factors
 Associated Factors
 Patient’s Perception
 Pain Assessment (PQRSTU Method)
 P: Provocative or Palliative
 Q: Quality or Quantity
 R: Region or Radiation
 S: Severity Scale
 T: Timing
 U: Understand Patient’s Perception of the Problem
o Past Health
 Childhood Illnesses
 Accidents or Injuries
 Serious or Chronic Illnesses
 Hospitalizations
 Operations
 Obstetric History
 Immunizations
 Last Examination Date
 Allergies
 Current Medications
o Family History
 Blood relatives
o Review of Systems
 Purposes are to evaluate the past and present health state of each body system, to double-
check in case any significant data were omitted in the Present Illness section, and to
evaluate health promotion practices
 Order of the examination of body systems is roughly head to toe
 General Overall Health State
 Present weight, fatigue, weakness or malaise, fever, chills sweats or night sweats
 Skin, Hair, and Nails
 History of skin disease, pigment or color change, change in mole, excessive
dryness or moisture, pruritus, excessive bruising, rash or lesion
 Recent hair loss or change in texture
 Change in shape, color, or brittleness of nails
 Head
 Any unusually frequent or severe headache; any head injury, dizziness (syncope),
or vertigo
 Eyes
 Difficulty with vision, eye pain, diplopia, redness or swelling, watering or
discharge, glaucoma, or cataracts
 Ears
 Nose and Sinuses
 Mouth and Throat
 Neck

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  Breast
 Axilla
 Respiratory System
 Cardiovascular
 Peripheral Vascular
 Gastrointestinal Urinary System
 Male Genital System
 Female Genital System
 Sexual Health
 Musculoskeletal System
 Neurologic System
 Hematologic System
 Endocrine System
o Functional Assessment – measures a person’s self-care ability in the areas of general physical
health; ADLs; instrumental ADLs; nutrition; social relationships and resources; self-concept and
coping; and home environment
 Activities of Daily Living (ADL)
 Self-Esteem, Self-Concept
 Activity/Exercise
 Sleep/Rest
 Nutrition/Elimination
 Interpersonal Relationships/Resources
 Spiritual Resources
 FICA Questions
 Coping and Stress Management
 Personal Habits
 Alcohol
 Illicit or Street Drugs
 Environment/Hazards
 Intimate Partner Violence
 Occupational Health
o Perception of Health

Chapter 8: Assessment Techniques and Safety in the Clinical Setting (p 113-124)

 Physical Examination Techniques
o Inspection – a concentrated watching
 Begins the moment you first meet the person and develop a “general survey”
o Palpation – applies your sense of touch to assess the following factors: texture; temperature;
moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity,
crepitation, presence of lumps or masses, and presence of tenderness or pain
o Percussion – tapping the person’s skin with short, sharp strokes to assess underlying structures
o Auscultation – listening to sounds produced by the body, such as the heart and blood vessels and
the lungs and abdomen
 Equipment
o Stethoscope
 Diaphragm
 Bell
o Otoscope
o Ophthalmoscope
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  Standard Precautions

Chapter 9: General Survey and Management (p 125-130, 136-138)

 General Survey – study of the whole person, covering the general health state and any obvious physical
characteristics
o An introduction for the physical examination that will follow; it gives an overall impression of
the person
o Includes objective parameters that apply to the whole person, not just one body system
 Components of the General Survey
o Physical Appearance – age, sex, level of consciousness, skin color, facial features, overall
appearance
o Body Structure – stature, nutrition, symmetry, posture, position, body build, contour, obvious
physical deformities
o Mobility – gait, range of motion
o Behavior – facial expression, mood and affect, speech, speech pattern, dress, personal hygiene
 Abnormalities
o Hypopituitary Dwarfism
o Gigantism
o Acromegaly (Hyperpituitarism)
o Achondroplastic Dwarfism
o Anorexia Nervosa
o Endogenous Obesity – Cushing Syndrome
o Marfan Syndrome

Chapter 11: Pain Assessment

 Structure of Pain
o Development of Pathologic Pain
 Nociceptive Processing
 Neuropathic Processing
o Important to understand how these two types of pain develop because patients present with
distinguishing sensations and respond differently to analgesics
o Accurate pain assessments allow clinicians to more accurately select effective pharmacologic
and nonpharmacologic strategies to obtain improved clinical results
o Nociceptors – specialized nerve endings designed to detect painful sensations
 Located in the skin; joints; connective tissue; muscle; and thoracic, abdominal, and pelvic
viscera
 Nociceptive Pain
o Develops when functioning and intact nerve fibers in the periphery and CNS are stimulated
o Triggered by outside events from the nervous system as a result of actual or potential damage
o Can be divided into 4 phases
 Transduction
 Occurs in response to noxious stimuli
 Injured tissues release a variety of chemicals
 Neurotransmitters lead to pain propagation along sensory afferent nerve fibers to
the spinal cord and terminates in the dorsal horn
o Second set of neurotransmitters carry the pain signal
 Transmission
 Pain impulse moves from the level of the spinal cord to the brain
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  If pain is not stopped, the pain impulse moves via various ascending fibers within
the spinothalamic tract to the thalamus
 Perception
 Signifies the conscious awareness of a painful sensation
 Cortical structures (i.e., limbic system) account for the emotional response to pain
 Only when the noxious stimuli are interpreted in the higher cortical structures can
the sensation be identified as “pain”
 Modulation
 Body has a built-in mechanism that will slow down and stop the processing of a
painful stimulus
 Descending pathways release a third set of neurotransmitters that produce an
analgesic effect
o Normal nociceptive processing is protective and can be a warning signal
that injury is about to or has taken place
o Other examples of nociceptive pain include a skinned knee, kidney stones,
menstrual cramps, muscle strain, etc.
 Neuropathic Pain
o Pain that does not adhere to the typical phases in nociceptive pain
o Pain due to a lesion of disease in the somatosensory nervous system
 Neuropathic pain implies an abnormal processing of the pain message that is difficult to
assess and treat
 Often perceived long after the site of injury heals
o Conditions that may cause neuropathic pain include diabetes mellitus, herpes zoster (shingles),
HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, and/or chemotherapy
o Diagnosis
 Pain sustained on a neurochemical level cannot be identified by x-ray, computerized axial
tomography (CAT) scan, or magnetic resonance imaging (MRI)
 Electromyography and nerve-conduction studies are needed
 Abnormal processing of neuropathic pain impulse can be continued by the PNS or CNS
o Proposed Mechanisms
 Spontaneous and repetitive firing of nerve fibers, almost seizure like in activity
 Neuropathic pain may be sustained centrally in a phenomenon known as neuronal “wind-
up”
 Central neuron hyperexcitability leads to maintenance of neuropathic pain
 Minor stimuli can lead to significant pain
 Sources of Pain
o Physical pain sources are based on their origin
o Visceral Pain – originates from the larger interior organs
 Stems from direct injury to organ or from stretching of the organ from tumor, ischemia,
distention, or severe contraction
 Pain impulse is transmitted by ascending nerve fibers along with nerve fibers of the
autonomic nervous system (ANS)
 Visceral pain often presents with autonomic responses such as vomiting, nausea, pallor,
and diaphoresis
o Somatic Pain – originates from musculoskeletal tissues or the body surface
 Deep Somatic Pain – comes from sources such as blood vessels, joints, tendons, muscles,
and bone
 Pain may result from pressure, trauma, or ischemia

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  Described as aching or throbbing
 Cutaneous Pain – derived from skin surface and subcutaneous tissues
 Pain is superficial, sharp, or burning
 Somatic Pain is usually well localized and easy to pinpoint
 Like visceral pain, can be accompanied by nausea, sweating, tachycardia, and
hypertension caused by the ANS response
o Referred Pain – felt at a particular site but originates from another location
 Both sites are innervated by the same spinal nerve, and it is difficult for the brain to
differentiate point of origin
 May originate from visceral or somatic structures
 Various structures maintain their same embryonic innervation
 It is useful to have knowledge of areas of referred pain for diagnostic purposes
 Types of Pain
o Pain can be classified by its duration and its duration provides information on possible
underlying mechanisms and treatment decisions
o Acute Pain – short term and self-limiting, often follows a predictable trajectory, and dissipates
after injury heals
 Examples include surgery, trauma, and kidney stones
 Has self-protective purpose; it warns the individual of actual or threatened tissue damage
 Incident Pain – an acute type that happens predictably when certain movements take
place
 Examples include pain in the lower back on standing or whenever turning a
hospitalized patient from side to side
o Chronic (Persistent) Pain – diagnosed when the pain continues for 6 months or longer
 Malignant (Cancer-Related) Pain
 Often parallels pathology created by the tumor cells
 Pain is induced by tissue necrosis or stretching of an organ by the growing tumor
o It fluctuates within the course of the disease
 Nonmalignant Pain
 Often associated with musculoskeletal conditions such as arthritis, low back pain,
or fibromyalgia
 Does not stop when the injury heals
 It persists after the predicted trajectory
 Outlasts its protective purpose, and the level of pain intensity does not correspond with
the physical findings
 Many chronic pain sufferers are not believed by clinicians and are labeled as malingerers,
attention seekers, or drug seekers
o Breakthrough Pain – transient spike in pain level, moderate to severe in intensity, in an otherwise
controlled pain syndrome
 Can result from end of dose medication failure
 Can also be the result of incident or episodic pain
 Treatment includes shortening the interval between doses or increasing the dose of
medication
 The experience of pain is a complex biopsychosocial phenomenon
 More clinical research is needed to filly understand the complexities of the pain
experience
 Rely on patient report as the best indicator of pain
 Developmental Competence

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 o Infants have the same capacity for pain as adults
 In fetal development, ascending pathways are developed by 20 weeks gestation, but
perception of pain may not be seen until 30 weeks gestation due to immaturity of cortex
and lack of conscious awareness
 Inhibitory neurotransmitters are insufficient until birth at full term
 Therefore, preterm infant is rendered more sensitive to painful stimuli
o No evidence exists to suggest that older individuals perceive pain to a lesser degree or that
sensitivity is diminished
 Although pain is a common experience among individuals 65 years of age and older, it is
not a normal process of aging
 Pain indicates pathology or injury
 Pain should never be considered something to tolerate or accepts in one’s later years
 Many clinicians or older adults wrongfully assume pain should be expected in
aging, which leads to less aggressive treatment
 Older adults have additional fears about becoming dependent, undergoing invasive
procedures, taking pain medications, and having a financial burden
 Most common pain-producing conditions for aging adults include pathologies such as
osteoarthritis, osteoporosis, peripheral vascular disease, cancer, peripheral neuropathies,
angina, and chronic constipation
 Dementia does not impact the ability to feel pain, but it does impact the person’s ability
to effectively use self- report tools
o Gender differences are influenced by societal expectations, hormones, and genetic makeup
 Traditionally, men have been raised to be more stoic about pain, and more affective or
emotional displays of pain are accepted for women
 Hormonal changes have strong influences on pain sensitivity for women
 Women are two to three times more likely to experience migraines during childbearing
years, more sensitive to pain during premenstrual period, and six times more likely to
have fibromyalgia
 Cultural Differences
o Most of the research conducted on racial differences and pain has focused on the disparity in the
management of pain for various racial groups
o Poorly treated pain has devastating results for the patient, with huge costs to society in losses of
wages and productivity
o Pain and the expression of pain are influenced by social, cultural, emotional, and spiritual
concerns
 Subjective Data
o Pain is defined as an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage
o Pain is a subjective experience and as such the person’s report is the most reliable indicator or
pain
o Pain occurs on a neurochemical level, so the diagnosis of pain cannot be made exclusively on
physical examination findings
o Self-report is the gold standard of pain assessment
 Initial Pain Assessment
o Do you have pain?
o Where is your pain?
o When did your pain start?
o What does your pain feel like?

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 o How much pain for you have now?
o What makes your pain better or worse?
o How does pain limit your function or activities?
o How do you usually react when you are in pain?
o What does this pain mean to you?
 Pain Assessment Tools
o Pain is multidimensional in scope, encompassing physical, affective, and functional domains
o Various tools have been developed to capture unidimensional aspects or multidimensional
components
o Select the pain assessment tool based on its purpose, time involved in administration, and the
patient’s ability to comprehend and complete the tool
 Rate and evaluate all the pain sites
 Use assessment tool consistently
o Reassessment of pain following intervention is essential to document pain trajectories alongside
various treatments to achieve optimum pain control
o Standardized overall pain assessment tools are more useful for chronic pain conditions or
particularly problematic acute pain problems
 Types of Pain Assessment Tools
o Initial Pain Assessment
 Asks the patient to answer 8 questions concerning location, duration, quality, intensity,
and aggravating/relieving factors
 Further, the clinician adds questions about the manner of expressing pain and the effects
of pain that impair one’s quality of life
o Brief Pain Inventory
 Asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10)
with respect to its impact on areas such as mood, walking ability, and sleep
o Short-Form McGill Pain Questionnaire
 Asks the patient to rank a list of descriptors in terms of their intensity and to give an
overall intensity rating to his or her pain
o Pain-Rating Scales
 Unidimensional and intended to reflect pain intensity
 Can indicate baseline intensity, track changes, and give some degree of evaluation to a
treatment modality
 Subtypes
 Numeric Rating Scales – asks the patient to choose a number that rates the level
of pain for each painful site, with 0 being no pain and 10 indicating the worst pain
ever experienced
 Verbal Descriptor Scale – uses words to describe the patient’s feelings and the
meaning of the pain for the person
 Visual Analogue Scale – lets the patient make a mark along a horizontal line from
“no pain” to “worst pain imaginable”
 Descriptor Scale – lists words that describe different levels of pain intensity such
as no pain, mild pain, moderate pain, and severe pain
 Selection of pain rating scale is based on patient understanding and age of development
o PQRST Method of Pain Assessment
 Provocation/Palliation
 Quality/Quantity
 Region/Radiation
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  Severity Scale
 Timing
 Tools for Infants and Children
o Because infants are preverbal and incapable of self-report, pain assessment depends on
behavioral and physiologic cues
 It is important to underscore the point that infants do feel pain
o Children 2 years of age can report pain and point to its location, but cannot rate pain intensity at
this developmental level
 Helpful to ask parent or caregiver what words the child uses to report pain
o Rating scales can be introduced at 4 to 5 years of age
 Faces Pain Scale-Revised (FPS-R) has 6 drawings of faces that show pain intensity, from
“no pain” on the left (score of 0) to “very much pain” on the right (score of 10)
 Realistic facial expressions are used
 Objective Data
o Preparation
 Physical examination process can help you understand the nature of the pain
 Is it an acute or chronic condition?
 Physical findings may not always support the patient’s pain reports, particularly
for chronic pain syndromes
 Pain should not be discounted when objective, physical evidence is not found
 Based on the patient’s pain report, make every effort to reduce or eliminate pain
with appropriate analgesic and nonpharmacologic intervention
 American Pain Society
 It is a priority to establish a diagnosis for the cause of acute pain, however,
consideration should be given to starting symptomatic pain treatment as the
diagnostic workup progresses
 A comfortable patient is better able to cooperate with diagnostic procedures
 Joints
 Note size, contour, and circumference of joint
 Check active or passive range of motion
 Joint motion normally causes no tenderness, pain, or crepitation
 Muscles and Skin
 Inspect the skin and tissues for color, swelling, and any masses or deformity
 Abdomen
 Observe for contour and symmetry
 Palpate for muscle guarding and organ size
 Note any areas of referred pain
 Nonverbal Behaviors of Pain
 When an individual cannot verbally communicate pain, you can (to a limited
extent) identify pain using behavioral cues
o Recall that individuals react to painful stimuli with a wide variety of
behaviors
 Behaviors are influenced by
o Nature of pain (acute versus chronic)
o Age
o Cultural and gender expectations
 Acute Pain Behaviors
 Involves autonomic responses and has a protective purpose
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  Individuals experiencing moderate-to-intense levels of pain may exhibit the
following behaviors
o Guarding
o Grimacing
o Vocalizations such as moaning
o Agitation
o Restlessness
o Stillness
o Diaphoresis
o Change in vital signs
 Chronic (Persistent) Pain Behaviors
 People with chronic pain often live with the experience for months or years
 Adaptation occurs over time and clinicians cannot look for or anticipate the same
acute pain behaviors to exist to confirm a pain diagnosis
 Have even more variability than acute pain behaviors
o Higher risk for under detection
 Behaviors associated with chronic pain include
o Bracing
o Rubbing
o Diminished activity
o Sighing
o Change in appetite
 Developmental Competence
o The Aging Adult
 Although pain should not be considered a “normal” part of aging, it is prevalent
 Older adults with history of comorbidities should anticipate pain
 Older adults often deny having pain for fear or dependency, further testing or invasive
procedures, cost, fear of taking painkillers or becoming a drug addict
 When looking for behavioral cues, look at changes in functional status
 Changes in dressing, walking, toileting, or involvement in activities
 Comorbidity of dementia may prevent patient from identifying and describing pain
 Observe behaviors
 Use PAINAD scale
 PAINAD Scale
 Evaluates five common behaviors: breathing, vocalization, facial expression,
body language, and consolability
 Specific behaviors are quantified from 0 to 2, with a total score ranging from0 to
10
 A score of 4 or more indicated a need for pain management

Documentation Accuracy
 Individual’s Record – a permanent legal document that provides a comprehensive account of
information about the individual’s health care status

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