Pain Assessment & Oxygen Saturation

FUNDAMENTALS OF NURSING PRACTICE(Lab)

NCM 103 | BLK 1 | PROF. Apple | SEM 2 2023

Pain Assessment
● a physiologic warning system
● malfunctioning segment of the
nervous system

Types of Pain
● Location
○ can radiate to other areas ● Etiology
○ Referred, arises in another ○ Nociceptive, temporary
area of the body pain, experienced when
○ Visceral, arising from tissues are damaged
organs or hollow viscera ■ Somatic, origin is
skin, muscle, bone,
or tissue
■ Visceral, activated
pain receptors in the
organ
○ Neuropathic, due to
damaged or malfunctioning
nerves, typically chronic
■ Peripheral
Neuropathic,
damage or
● Duration
sensitization or
○ Acute, < 3 months, sudden
peripheral nerves
or slow onset
■ Central
○ Chronic, persistent pain,
Neuropathic,
can be beyond 3 months to
malfunctioning
years
nerves in CNS
○ Cancer-related, a result of
direct-effect of the disease
and its treatment

● Intensity

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Pain Assessment & Oxygen Saturation
FUNDAMENTALS OF NURSING PRACTICE(Lab)
NCM 103 | BLK 1 | PROF. Apple | SEM 2 2023
Pain Assessment
● Must obtain facts from the client
● tools used are based on age,
developmental level, and cognitive
function
● Documenting pain locations by
using landmarks or terms such as
proximal, distal, medial, lateral,
and diffuse
● Directly observe the client for
behavior, physical signs of tissue
damage, secondary physiologic
responses of the client
IMPORTANT INFO
The best interpreter of pain is the
CLIENT
● Child’s pain
○ let the child point the pain
○ may use figure drawings
○ parents can interpret the
child’s words
● Pain Quality
○ Report the pain of the client
as verbalized, do not
interpret
● Precipitating Factors
○ Physical Exertion, chest
pain, abdominal pain,
muscle spasms
○ Environmental Factors.,
extreme cold or heat,
extreme humidity
○ Physical and Emotional
Stressors, strong emotions
● Alleviating Factors
○ ask the client what they do
to alleviate their pain
● Associated Factors
○ What are the other
occurring symptoms with
the pain of the client
○ Assess what adds to the
pain
● Effect on Activities of Daily
Living (ADLs)
● Coping Resources
○ encourage and support the
client’s way of alleviating
pain unless contraindicated
● Affective Responses
○ explore the client’s feelings
● Observation of Behavioral and
Physiologic Responses
○ Facial expressions,
Vocalizations,
Immobilization of the body
or a part, Purposeless Body
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Pain Assessment & Oxygen Saturation
FUNDAMENTALS OF NURSING PRACTICE(Lab)
NCM 103 | BLK 1 | PROF. Apple | SEM 2 2023

Movements, Behavioral
Changes, Rhythmic Body
Movements, Physiologic
Responses
● Daily Plan Diary
○ the basis for developing or
modifying the plan for care
○ Let client have the “sense
of control”
○ allow the client to
understand and express
their pain experience
○ Review the client’s diary
each visit, ask questions,
share observations, and
provide hints

Pain Intensity Scales

● Provides consistency
● Easy method to determine
patient’s pain
● Neonatal Infant Pain Scale
(NIPS), premature infants to 3
months of age
● Facial expressions, Leg
movement, Activity, Cry, and
Consolability (FLACC) Scale,
children 2 months up to Oxygen Saturation
adolescence ● Pulse Oximeter
● Pain Assessment in Advanced ○ noninvasive device to
Dementia (PAINAD), for older estimate SpO2 by means of
adults with advanced dementia a sensor
○ Indicators, breathing,
vocalization, facial
expression, body language,
consolability

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Pain Assessment & Oxygen Saturation
FUNDAMENTALS OF NURSING PRACTICE(Lab)
NCM 103 | BLK 1 | PROF. Apple | SEM 2 2023

● Check if the client is allergic to the

adhesive

● Normal SpO2
○ 95%-100%
○ Below 90%, for evaluation
and treatment
○ Below 70%, life-threatening

Factors Affecting SpO2 Readings

● Hgb Levels
○ if Hgb is fully saturated
with O2, SpO2 is normal
even if total Hgb level is low
● Circulation
○ if area under the sensor is
impaled = inaccurate
reading
● Activity
○ shivering or excessive
movement = inaccurate
reading
● CO Poisoning
○ pulse oximeters cannot
discriminate Hgb saturated
with CO vs O2

Assessing SpO2 Saturation

● Best location for adults = finger
● Assess the client’s overall
condition, check for risk factors for
development of hypoxemia and
Hgb level
● Check VS of the client