Assessment Techniques and Pain Assessment

For educational purposes only. 

Today we learn about what entails an assessment and the techniques we use as nurses. 

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Transcript

Welcome back to Rosie the Riveting RN, I am professor poole, your nursing school professor who will help you break down tough concepts taught in nursing school. I hope you are having a wonderful day today. We will go over first, different assessment techniques and then wrap up with how to do a pain assessment. 

Our assessment skills is what sets us apart from LVNs. You need to have great assessment skills to know when the patient is declining, having complications, or compensating from a disease. Our assessment skills are our holy grail to what makes us nurses. We spend more time with the patient than anyone else and we need to know what is our patients’ norm and what is not. 

As you enter the room, the first thing you need to do is your filthy hands and make sure the patient sees you doing this. This way, they know your not nasty. Hand hygiene will forever be your way of life. Ever seen the Mandalorian? This IS THE WAY. 

First part of assessment is inspection. It is the very first thing we do naturally. The moment you lay eyes on the patient, we are assessing, inspecting, and interpreting what we are seeing. Just like the general survey. It starts the moment we lay eyes on you. Make sure there is good lighting in the room, there are no distractions, and please be sure to not just stare at the patient. This will take some time to get down. 

The next step is palpation. Be sure to warm your hands up because when we have icy hands, it can cause the patient to tense up and we can receive false interpretations. As nurses, we only do light palpation, we leave the deep stuff to the docs. We are feeling for moisture, or lack-there-of, body temperature, tenseness, tenderness, rigidity, guarding, lumps, bumps, swelling, cracking, crepitation, pulses, just to name a few. 

We use our fingertips to assess for changes of sensation or thickness of the skin to organ. This can be assessing edema, pulses, skin sensation or texture, or even lumps. To assess the temperature of the skin it is best to use the backside of your hand. We do this because the skin on your palms is thicker which can give a false sense of temperature. To test for vibration we use the base of our fingers. You can do this when you believe a patient may have fluid in their lungs, you can have the base of your fingers on their back and have the patient say the word “99.” We will get more into that in the pulmonary assessment on a later date. Lastly we can use our fingers and thumbs to assess for organ size, shape, location, and mobility of a mass. 

We really do not do percussion anymore so I will not get into that. Which will then make auscultation our next step in the assessment. This is where we use those trusty stethoscopes! When doing this, be sure to eliminate any background noise by turing off or muting any music or television. This way, you get a better listen. Be sure to have the stethoscope in the right way by having the ear pieces sloping towards your nose. You will notice there is a big side, the diaphragm and the little side, the bell. The diaphragm you will use more often than not. This is used for high pitched sounds like regular heart, lung, and bowel sounds. When using this, be sure to firmly apply the diaphragm to the patient’s skin so you get the best listen. Then there is the bell, which is used for soft-low-pitched sounds. This is where we assess for bruits or murmurs, and extra heart sounds. Since this is for low-pitched sounds be sure to lightly apply this to the patient’s skin. Tips for using your stethescope: always keep it clean by using an alcohol wipe between all patients, warm up your stethoscope prior to appying to the patient the cold sensation can be quite shocking. Never listen through clothing, this gives false assessments. If a person is very hairy, you can wet the hair before applying the stethoscope, this will eliminate extra sounds caused by the hair. 

Always prep your environment appropriately by providing a safe environment that allows for privacy. If you are not in an area, like a PACU or pre-op area that just has curtains, use IMPLIED PRIVACY by closing the curtains. Use good lighting to get a good assessment and vision of the patient, and eliminate any possible distractors. This can be the TV, phone, computer, whatever could distract you and the patient. Ideally natural light is best, but this is not always feasible. We do like to use two different light sources to eliminate any shadowing or contouring that may give us a false assessment. We use tangential lighting (lighting at an angle) when we do need to assess certain couturing or pulsations of the body. You can think of tangential lighting as lighting in the dressing rooms. Just when you’re feeling good about yourself, you turn around to those mirrors and that god awful lighting, and you second guess that second portion of mama’s lasagna last night! That, my friends, is tangential lighting. 

Have your patient’s seat or the examination table positioned so you can access and assess the patient on both sides. This also allows you to easily access your tools for assessment. 

So, what kind of tools do you need to assess a patient? Well, a stethoscope is one for sure, but we have lots more. There is a pen light of inspection, a scale with height measurement, thermometer, pulse oximeter, tongue depressor, tunning fork and reflex hammer, sharp object and cotton ball for sensation assessments, and any specimen collection containers you may need to send off to lab. Bottom line, there is a lot. That’s not even all of the equipment you may need, but you get the picture. 

There have been plenty of times where we are in a patient’s room thinking they are standard precaution and then we get a call from the previous nurse, team lead, or even lab who let’s us know the patient should be some type of other precautions. It is very important to know what precautions your patients should be on so that you are not only protecting yourself, but also your other patients. 

What are all the different types of precautions? 

Standard- the run-of-the-mill precaution for everybody. You treat everyone as if they are contagious via bodily fluids. Wash your hands or use hand sanitizer before and after every interaction. Use gloves, if you think you will be exposed to some backsplash of some type of fluid, you are encouraged to wear eye protection and a gown. Other than that, you usually don’t wear a gown or goggles. 

Contact- this is your c. diff patient. This is the most common type of infection that will call for contact. Wear a gown and gloves and wash your hands with soap and water after leaving the room. Sanitizer will not kill c. diff. Also, you will need to use bleach on equipment that exits that room. The normal wipes used on units will not kill c. diff bacteria. 

Droplet- when patients have a cough. Usually some type of upper respiratory infection like the flu or pertussis. Wear a surgical mask and use standard precautions. 

Airborne- popularly used to TB patients. The room will need to be in negative pressure room, you will need a gown, N95 or a CAPR, eye protection, gloves, and you can use a hair net too if you wish. You do need to be properly fit for your N95. If there is not a good seal on the face, you risk getting TB, which is not fun to have. 

We want to create a comfortable environment for our patients. You may notice when you go to the doctor’s office, we get your weight, sometimes height, and then your vitals before doing a physical assessment on you. This allows the patient to ease into the routine of an assessment. During this time, you can ask ice breakers such as how their holiday season is going, compliment a piece of jewelry, or something along those lines. People love compliments and they love talking about themselves. This also gives you an opportunity to get to know your patient. After we gather the basics and the vitals, you tell the patient to change into a gown if needed and let them know if any undergarments need to be removed. Leave the room for the patients privacy. When re-entering the room, knock on the door and ask if the patient is ready for you to enter. Providing privacy and respecting modesty is one way to build respect and rapport with the patient. As you re-enter the room, re-do your hand hygiene in the patient’s presence. 

As you go through your assessment, explain to the patient what you are doing. If you are lingering in an area a little longer for a better assessment, just inform the patient what you are doing so they do not get worried something is wrong. For example, when you listen to the heart for a little longer, let them know that is your routine, and you just wanted to get a good listen. If everything sounded normal, let them know. 

As you move through each body part, you can provide teaching specifically for that body part. Going back to the example of listening to the heart, you can teach the patient what you are listening for and what you heard, and that it is normal. Or, if a patient is really edematous, you can ask and teach them about sodium intake. As you wrap up your assessment, you can give the patient a summary of what you found. Prior to leaving the room, have the patient in a comfortable position and be sure to lower the bed, so the patient does not fall getting out of it. 

When working with an aging adult, you will want to organize your assessment so that the patient does not need to reposition frequently or lay down and sit back up repeatedly. The elderly adult may have a hard time moving, so make their assessment as smoothly as possible for them. You may need to go at a slower pace for the elderly patient due to their comorbidities and their own slower movements. The elderly patient will also have a longer history than younger patient, and they may take longer to assess. Still use the head-to-toe sequence on this patient as you would any other patient. Touch can be helpful for an older patient because visions and or hearing can be diminished. That being said, just because a patient cannot hear or see well, does mean they have declining mentation or altered mental status. The patient can be very aware of what is going on with their body and environment, but they just have diminished hearing or vision. 

For any sick patients, you will want to cater your assessment around that illness or disease. For example, a patient with an exacerbation of HF may not be able to lay flat, so don’t have the patient lay flat. You can have them sit upright, Fowler’s or semi-Fowler’s position. Remember, when a patient is sick, we collect a mini-database to assess the problematic areas of the body so that we can best help the patient. If a complete assessment is needed later, we can do that at a later time. But for this sick patient, gather the pertinent information to assist the patient best for their illness. 

Now, let’s get into pain!

It is good to know the different types of pain. 

nociceptive pain is when peripheral nerves are fully functioning and intact, and some type of injury occurs. This sends a message to the CNS that an injury has occurred. This can be caused by potential or actual trauma to tissues. The rate which our body receives and interprets the pain information allows us to protect ourself from further damage, or react to pain in a certain way. For example, if we touch something that is sharp, we pull away from the noxious pain stimulation due to the rate that pain information is sent to our brain, how fast our brain interprets that information, and how fast our brain sends our body a message to react a certain way. 

Neuropathic pain- nerve pain usually described as a burning sensation, or the patient may feel there is a burning sensation shooting down a limb. There is something affecting the nerve fibers and how pain information is being received. This is more of a chronic issue and can occur well after tissues have recovered. Nociceptive pain can eventually morph in to neuropathic pain. Things that can cause neuropathic pain are diabetes, chemotherapy, phantom leg pain, and sciatica just to name a few. 

Through our assessment skills and hearing how the patient describes the pain, we can identify the sources of the pain. 

Visceral- described as dull, cramping, squeezing, or deep pain that is caused by a large organ. 

Somatic pain- contains deep or cutaneous pain. Deep somatic pain- caused by ischemia, pressure (maybe caused by edema or internal bleeds), or trauma. This comes from vessels, bones, musculoskeletal structures. Described as achy throbbing pain. CUTANEOUS PAIN- skin level and subcutaneous level injuries and is described as sharp pain that is superficial. 

Referred pain- pain felt in a different area from the original site. This can happen with appendicitis where you feel lower left quadrant pain, but the problem is your appendix, which is in the right lower quadrant. The reason this happens is because both can be innervated by the same nerve. 

We want to know how long patients have been having their pain for. This is broken up into acute and chronic pain. Acute is when there is an injury and usually lasts until the injury heals. Usually less than 6 months. Chronic pain lasts long after an injury heals and lasts well after six months. This can be hard to treat and control. We do not like to give these patient opioids due to the dependency it can cause in the long run. We now have pain specialists that can help patients who are  looking in to more hollistic and natural ways to treat chronic pain. 

Breakthrough pain- happens when a pain medicine is given, but the patient experiences a spike in pain prior to the next pain med’s dosage. This is seen in many different situations, my experience I would see this with my cancer patients. We would need a different pain med to hold the patient over until the next dosage. For example, a patient has oxicodone every 6 hours, but at the 4 hour mark, the patient is experiencing more pain. We can have a PRN dose of a different pain med to be given specifically for breakthrough pain to hold that patient over for those next two hours, maybe even more. 

When dealing with elderly patients, it is important to note that pain is not a normal finding to aging. No population should be expected to live in pain. If the patient says they are in pain, we listen to them and try to find out why. Patients who have dementia still experience pain the same way, but they have a difficult time communicating their pain. When you have these patients start to become irritable, grumpy, angry, or just a change in their attitude, they may be having pain and may need pain intervention. 

How do we assess pain in our patients? Many of it is going to be based on subjective information. That is the gold standard for assessing pain. We straight up ask the patient, do you have pain? Where is it? What causes it and what makes it better? How would you rate your pain, does it radiate? How long does it last for? How long have you had this pain? 

Older adults may under report pain for fear of dependency, needing more help/interventions, or for being a burden. Look for cues that indicate pain and assure the patient is it okay to admit if they are in pain. Some adults may worry about being addicted to pain meds, but you can educate them on how we use pain meds.