NCM101: HEALTH ASSESSMENT

LESSON 1
A. Definition and Purpose Types of Nursing Assessments C. Working Phase
●​ Health assessment involves the systematic collection, A. Initial Comprehensive Assessment ●​ Collect subjective data:
validation, and documentation of client data. -​ Conducted during the first interaction. -​ Ask questions about biographical data, present health
●​ Aimed at determining a client's overall health status, it -​ Covers a complete health history and physical concerns, past health history, and lifestyle practices.
includes physical, psychological, sociocultural, examination. -​ nUse effective communication skills:
developmental, and spiritual aspects. B. Ongoing/Partial Assessment -​ Open-ended questions to encourage detailed
-​ Periodic follow-ups to monitor progress and update responses.
B. Nurse's Role in Health Assessment data. -​ Clarify responses using techniques like rephrasing or
●​ Nurses utilize assessment skills to make clinical C. Focused/Problem-Oriented Assessment summarizing.
judgments and guide care decisions. de care decisions. -​ Centers on a specific issue (e.g., chest pain). -​ Collaborate with the client to identify problems and
●​ Holistic focus differentiates nursing assessments from D. Emergency Assessment goals.
medical assessments. -​ Rapid assessment during critical situations to ensure
immediate intervention D. Summary and Closing Phase
Evolution of Nurse's Roles in Health Assessment -​ Summarize key findings
Historical Perspective Components of Health Assessment -​ Review the data collected and validate it with the client.
●​ Early nursing roles focused on hygiene and basic A. Collecting Subjective Data -​ Discuss next steps:
caregiving tasks. 1. Health History -​ Identify immediate needs and possible care plans.
●​ Assessment was limited to observing visible symptoms -​ Biographical data, chief complaints, history of present -​ Encourage questions
and reporting them to physicians. illness (using COLDSPA: Character, Onset, Location, -​ Ensure the client's concerns are addressed.
Duration, Severity, Pattern, Associated factors).
Development of Independent Practice 2. Personal and Family Health History Communication Techniques in Subjective Data Collection
●​ With advances in education and practice, nurses began -​ Identifies risk factors and hereditary conditions. A. Verbal Communication
taking on more diagnostic roles. 3. Lifestyle and Health Practices ●​ Open-Ended Questions
●​ The introduction of nursing theories emphasized holistic -​ Nutrition, activity, stress levels, and coping mechanisms. -​ Encourage clients to share detailed
care, including physical, emotional, and social information
well-being. Phases of the Nursing Interview -​ e.g., "How have you been feeling lately?").
A. Pre-Introductory Phase ●​ Closed-Ended Questions
Modern Nursing Practice -​ Review the client's medical record and gather basic -​ Gather specific facts (e.g., "When did the pain
●​ Nurses are now primary care providers in many biographical data. start?").
settings, conducting comprehensive assessments. -​ Identify key issues such as hearing impairments or ●​ Rephrasing
●​ Use of advanced technology and evidence-based language barriers. -​ Clarify and confirm information (e.g., "You've
practice enhances diagnostic accuracy. been feeling tired and nauseated for two
●​ Specialized roles (e.g., Nurse Practitioners) require B. Introductory Phase months?").
advanced assessment skills. -​ Establish rapport: ●​ Providing Information
-​ Introduce yourself and explain your role. -​ Answer client questions and provide health
C. The Nursing Process -​ Provide a clear explanation of the interview purpose. education when appropriate
●​ Assessment: Collect subjective and objective data. -​ Ensure privacy and confidentiality:
●​ Diagnosis: Analyze data to identify health issues. -​ Explain HIPAA guidelines to reassure the client. B. Nonverbal Communication
●​ Planning: Establish goals and strategies. -​ Build trust: ●​ Body Language
●​ Implementation: Execute care plans. -​ Use open body language and an approachable -​ Maintain open posture and make eye
●​ Evaluation: Assess outcomes and refine interventions. demeanor. contact.
NCM101: HEALTH ASSESSMENT
●​ Facial Expressions -​ Address any questions or concerns.
-​ Use neutral or supportive expressions to ●​ Angry Clients:
encourage openness. -​ Stay calm and maintain a safe environment. C. Standard Precautions
●​ Silence ●​ Depressed Clients: -​ Perform hand hygiene before and after contact.
-​ Allow time for the client to think and respond. -​ Respond with empathy and neutrality. -​ Use gloves and other personal protective equipment
●​ Listening Skills ●​ Seductive Clients: (PPE) as needed
-​ Actively listen without interrupting or showing -​ Set firm boundaries and involve a witness if -​ Clean and disinfect equipment appropriately
distraction necessary
Techniques of Physical Examination
Components of a Complete Health History C. Cultural Sensitivity A. Inspection Definition:
A. Biographical Data ●​ Be aware of cultural differences in communication -​ Systematic visual examination of the body's
-​ Name, age Name, age, gender, occupation, and cultural styles and health perceptions. appearance.
background. ●​ Use interpreters when language barriers exist. -​ Observe size, shape, color, symmetry, and position
B. Reasons for Seeking Care -​ E.g. (Inspect skin for lesions or discoloration.)
-​ Document the client's primary concerns or health issues D. Collecting Objective Data
in their own words. ●​ Use physical examination techniques: B. Palpation
C. History of Present Health Concern -​ Inspection: Observing appearance and -​ Definition: Using hands to feel for texture, temperature,
-​ Use the COLDSPA mnemonic to gather details: behavior moisture, organ size, and tenderness.
●​ Character: Description of symptoms -​ Palpation: Feeling for abnormalities. -​ E.g. (Palpate the abdomen for tenderness or masses.)
●​ Onset: When symptoms began. -​ Percussion: Tapping to assess underlying -​ Types:
●​ Location: Where the issue is felt. structures ●​ Light Palpation, Assess surface
●​ Duration: Length of time symptoms persist -​ Auscultation: Listening to body sounds (e.g. characteristics (e.g., skin, texture).
●​ Severity: Intensity of symptoms (e.g., pain heart, lungs). ●​ Deep Palpation: Evaluate deeper structures
scale (e.g., liver size)
●​ Pattern: What aggravates or alleviates Challenges in Data Collection and Solutions -​ Parts of the Hands Used in Palpation
symptoms. A. Common Barriers Fingertips
●​ Associated Factors: Other symptoms present. -​ Language differences. -​ Best for fine tactile discrimination, such as
D. Personal and Family Health History -​ Emotional or cognitive impairments. texture, swelling, and pulsations
-​ Identify past medical events and hereditary conditions. -​ Reluctance to share personal information. Dorsal Surface (Back of Hand)
E. Lifestyle and Health Practices B. Strategies to Overcome Barriers -​ Most sensitive to temperature.
-​ Explore daily habits such as diet, exercise, stress -​ Use culturally appropriate communication teacher Base of Fingers (Metacarpophalangeal Joints)
management, and social activities. build trust through empathy and active listening -​ Useful for detecting vibrations.
-​ Simplify questions and ensure understanding. Palmar Surface:
Adapting the Interview for Special Populations -​ Effective for assessing general surface
A. Older Adults Preparing for the Physical Examination characteristics and firmness.
-​ Speak clearly and allow more time for A. Environment
responses. -​ Ensure the setting is private, well-lit, and comfortable. C. Percussion
-​ Address sensory impairments (e.g., hearing -​ Organize equipment to minimize interruptions -​ Tapping the body to assess underlying structures by
loss). sound production.
B. Clients with Emotional Needs B. Client Preparation -​ E.g. ( Percuss the chest to assess lung function.)
●​ Anxious Clients: -​ Explain the procedure and gain informed consent.
-​ Provide structured, simple information. -​ Maintain the client's comfort, privacy, and dignity. Types of Sounds:
NCM101: HEALTH ASSESSMENT
-​ Resonance: Normal lung sound. B. Techniques for Accurate Documentation
-​ Tympany: Normal abdominal sound. -​ Use clear, concise, and specific language. C. APPARENT VS. REPORTED AGE
-​ Dullness: Indicates solid organs or masses. -​ Include both subjective and objective findings. -​ Does the person appear their stated age? Chronic
-​ Avoid vague terms like "good" or "fair." illness or environmental factors (e.g., excessive sun
D. Auscultation exposure) can make someone look older.
-​ Listening to body sounds, typically with a stethoscope. C. Validation
-​ Ensures data accuracy by cross-checking with the D. SKIN CONDITION AND COLOR
Common Areas: client or other sources. -​ Normal skin color varies but should be even, without
-​ Heart: Assessing rate, rhythm, and murmurs. -​ Identifies discrepancies or missing information lesion
-​ Lungs. Detecting breath sounds (e.g., wheezing, -​ Pale or flushed skin may indicate anemia or fever, while
crackles). LESSON 2 yellowing may suggest jaundice.
-​ Abdomen: Listening for bowel sounds. HEALTH ASSESSMENT IN NURSING - general Health Status and Vital
Signs E. DRESS AND HYGIENE
Documenting and Validating Objective Data -​ Is the client dressed appropriately for the weather or
A.​ Documentation Guidelines I. INTRODUCTION occasion?
-​ Use clear, concise, and standardized terminology. HEALTH ASSESSMENT -​ Poor hygiene could signal depression, homelessness, or
-​ Record findings immediately to ensure accuracy. -​ one of the most critical skills for nurses. cognitive impairment.
-​ Include both normal and abnormal findings. -​ collecting data to evaluate the physical, emotional, and
B.​ Validation psychological status of a client. F. POSTURE AND GAIT
-​ Cross-check findings with the client and other -​ Observe how they stand and walk. A slumped posture
healthcare team members. 1. GENERAL SURVEY might indicate depression, while stiffness could point to
-​ Reassess if data are inconsistent or unclear. -​ first part of a physical examination. arthritis.
-​ begins as soon as you meet the client and continues as -​ For older adults, watch for kyphosis (curved spine) or a
Challenges in Physical Examination and Solutions you observe the appearance, behavior, and waddling gait, which may result from balance issues.
A.​ Common Challenges interactions.
-​ Client anxiety or discomfort. -​ forming a first impression. G. BEHAVIOR AND SPEECH
-​ Time constraints in busy clinical settings. -​ Pay attention to their facial expressions, eye contact,
-​ Limited access to advanced diagnostic tools. WHAT IS INCLUDED IN THE GENERAL SURVEY? and speech patterns.
A. PHYSICAL DEVELOPMENT AND BODY BUILD -​ Signs like frowning or grimacing may indicate pain,
B.​ Strategies to Overcome Challenges ●​ Observe the client's body structure (average build, while slurred speech could suggest neurologic issues.
-​ Build rapport and explain each step of the muscular, or underweight)
exam. -​ Look for signs of malnutrition (e.g., prominent bones, II. VITAL SIGNS
-​ Prioritize assessments based on client muscle wasting) or obesity. VITAL SIGNS
condition. -​ For example, conditions like CUSHING SYNDROME cause -​ body's indicators of health.
-​ Use portable diagnostic aids when necessary. centralized weight gain (e.g., "buffalo hump"), while -​ Abnormal vital signs often signal issues in one or more
anorexia nervosa leads to extreme weight loss. systems, such as the cardiovascular or respiratory
Documenting and Validating Data systems.
A. Importance of Documentation B. GENDER AND SEXUAL DEVELOPMENT
-​ Ensures effective communication among healthcare ●​ Check if their sexual development is appropriate for A. TEMPERATURE
-​ Forms the foundation for clinical judgments and care their gender and age. 1. NORMAL RANGE
plans. -​ For instance, a male client with female secondary ●​ 36.5°C to 37.7°C (96.0°F to 99.9°F) orally.
-​ Creates a legal record of care provided. sexual characteristics may have hormonal imbalances.
NCM101: HEALTH ASSESSMENT
●​ Older adults may have slightly lower temperatures -​ Taking both (right and left) pulses at the same time
(35.0°C to 36.4°C). ➤ RECTAL TEMPERATURE may cause fainting
-​ Use lubrication and insert 1 inch into the rectum. Avoid ➤ FEMORAL PULSE:
METHODS OF MEASUREMENT in cases of rectal surgery or diarrhea. -​ Found in the groin area,
➤ ORAL -​ used for checking circulation to the legs.
-​ Most common and convenient ➤ TYMPANIC TEMPERATURE (Ear) ➤ POPLITEAL PULSE
-​ not for unconscious clients. -​ Gently place the probe in the ear canalThis is a good -​ Located behind the knee,
➤ RECTAL reflection of core temperature. -​ assess circulation to the lower extremities.
-​ Most accurate but invasive. ➤ POSTERIOR TIBIAL PULSE:
-​ Avoid clients with rectal surgery. ➤ TEMPORAL (Forehead) -​ Found on the inside of the ankle
➤ TYMPANIC (Ear) -​ assess circulation in the feet.
-​ Quick and safe Hypothermia (<36.5°C) ➤ DORSALIS PEDIS PULSE:
-​ reflecting core body temperature. -​ Seen in hypoglycemia, prolonged cold exposure, or -​ Located on the top of the foot
➤ AXILLARY hypothyroidism. -​ assess circulation to the foot.
-​ Common in infants
-​ less accurate. Hyperthermia (>38.0°C) FACTORS AFFECTING PULSE
➤ TEMPORAL (Forehead) -​ Indicates infection, trauma, or Inflammatory disorders. A. AGE
-​ Noninvasive and quick -​ As people age, their pulse rate tends to decrease.
-​ affected by sweating (less accurate) B. PULSE -​ Infants and children generally have a faster pulse
PULSE compared to adults.
FACTORS AFFECTING TEMPERATURE -​ reflects heart function B. GENDER
➤ TIME OF DAY -​ measured at various arterial sites -​ Women tend to have slightly faster pulses than men,
-​ Body temperature is lowest in the early morning -​ radial pulse being the most common. primarily due to hormonal differences.
(4:00-6:00 AM) and highest in the evening (8:00 C. BODY TEMPERATURE
PM-12AM) 1. PULSE SITES -​ Fever can cause an increase in pulse rate due to the
➤ EXERCISE AND STRESS PULSE is the rhythmic throbbing of arteries as blood is propelled body's attempt to regulate its temperature.
-​ increase body temperature. through them, typically due to the contraction of the heart. -​ Fever increases temperature but never the blood
-​ Exercise: increase in metabolism pressure
-​ Stress: Body is in a fight or flight response PULSE SITES around the body allow healthcare providers to assess D. EXERCISE
➤ HORMONAL CHANGES the heart's function and blood circulation. -​ Physical activity can elevate the pulse rate temporarily.
-​ Ovulation raises temperature slightly. -​ Regular exercise can lead to a lower resting pulse rate
➤ ENVIRONMENT MAIN PULSE SITES USED FOR ASSESSMENT: over time.
-​ Prolonged exposure to extreme temperatures can lead ➤ RADIAL PULSE: E. STRESS/EMOTIONS
to hypo- or hyperthermia. -​ Located on the lateral aspect of the wrist -​ Anxiety, fear, and stress can increase pulse rate due to
-​ one of the most common sites to measure pulse rate. the body's fight or flight response.
Correct Technique ➤ BRACHIAL PULSE: F. MEDICATIONS
➤ ORAL TEMPERATURE -​ Found in the antecubital fossa (inside of the elbow) -​ Drugs, particularly stimulants, can increase pulse, while
Use a thermometer with a disposable cover -​ often used in infants or when assessing blood pressure. medications like beta-blockers can slow it down.
-​ Place it under the tongue in the posterior sublingual ➤ CAROTID PULSE: G. HEALTH CONDITIONS
pocket. -​ Located in the neck, just beside the trachea, it's one of -​ Conditions such as fever, anemia, hyperthyroidism, and
-​ Ensure the client closes their lips around the the most palpable sites, especially in emergencies. heart disease can affect the pulse rate.
thermometer.
NCM101: HEALTH ASSESSMENT
-​ Pain increases blood pressure but never the -​ Strength of the pulse, graded as: C. STRESS AND EMOTIONS:
temperature 0: Absent. -​ Anxiety, fear, or stress can elevate resp rates through
H. POSITION 1+: Weak, diminished. stimulation of the sympathetic nervous system.
-​ A change in body position, such as from lying down to 2+: Normal. D. BODY TEMPERATURE:
standing, can temporarily alter the pulse rate due to 3+: bounding (strong, difficult to obliterate). -​ Fever increases metabolic rate, leading to faster
changes in blood circulation. breathing to meet oxygen demands.
C. RESPIRATION E. MEDICATIONS:
ATHEROSCLEROSIS, or hyperthyroidism, where the arteries lose RESPIRATION is the act of breathing, consisting of inhalation -​ Certain drugs, like opioids or sedatives, can depress
their elasticity, or the heart pumps excessively. (inspiration) and exhalation (expiration). respirations
-​ stimulants like caffeine can increase respiratory rates.
PULSE DEFICIT Inhale + Exhale = 1 Respiration
-​ occurs when there is a difference between the APICAL F. HEALTH CONDITIONS:
PULSE (heard at the heart) and the RADIAL PULSE (felt at CHARACTERISTICS TO ASSESS: -​ Respiratory diseases (e.g., asthma, pneumonia, chronic
the wrist). 1. RATE: obstructive pulmonary disease), metabolic acidosis,
-​ often occurs in patients with ARRHYTHMIAS, particularly -​ Normal respiratory rate for adults ranges from 12 to 20 and anemia can all alter breathing patterns.
atrial fibrillation, where some heartbeats do not result in breaths per minute.
effective ventricular contraction and are not palpable -​ Rates outside this range may indica underlying health G. POSITION:
at the peripheral pulse sites. issues. -​ Upright positions facilitate lung expansion, improving
-​ can be an indication of poor perfusion and ineffective 2. RHYTHM: breathing efficiency.
ca output. -​ The pattern of breathing should be regular. -​ Lying flat may restrict lung movement, in patients with
-​ Irregular rhythms could suggest conditions such as obesity or fluid overload.
ASSESSED BY counting the apical pulse (heard with a stethoscope respiratory distress or neurological issues.
over the chest) and radial pulse simultaneously for a full minute. If 3. DEPTH: FACTORS AFFECTING OXYGENATION AND RESPIRATORY FUNCTION
the apical pulse rate exceeds the radial pulse rate, a pulse deficit -​ Breaths should be even and moderate in depth. ➤ GAS EXCHANGE EFFICIENCY:
is present. -​ described as shallow, normal, or deep depending on -​ Conditions like emphysema, pulmonary edema, or
the extent of chest expansion. infections can impair oxygen-carbon dioxide exchange.
CLINICAL SIGNIFICANCE: 4. EFFORT: ➤ HEMOGLOBIN LEVELS:
Pulse deficit is commonly seen in patients with irregular rhythms, -​ Breathing should appear effortless. -​ Anemia or low hemoglobin can red oxygen-carrying
and its presence requires further investigation to deter the -​ Labored or strained breathing may indicate respiratory capacity, leading to faster or deeper bre to
underlying cause. complications. compensate.
➤ AIRWAY OBSTRUCTION:
CHARACTERISTICS TO ASSESS Factors Affecting Respirations -​ Blockages from foreign bodies, mucus, or inflammation
1. RATE: A. AGE: can impair airflow and breathing efficiency.
-​ NORMAL is 60-100 beats per minute (bpm). -​ Respiratory rates vary with age.
-​ TACHYCARDIA (>100 bpm): Seen in feverstress, or -​ Newborns and infants have higher rates (40-60) than ASSESSING RESPIRATIONS
anemia. adults (12-20) A. OBSERVATION:
-​ BRADYCARDIA (<60 bpm): May occur in athletes or with -​ elderly individuals may have slower or more shallow -​ Count breaths by watching the rise and fall of the chest
certain medications. respirations. without alerting the patient
2. RHYTHM: B. PHYSICAL ACTIVITY: -​ awareness may alter their breathing.
-​ Regular or irregular intervals between beats. -​ Exercise increases the rate and depth of respirations -​ Count for 30 seconds and multiply by 2 for the rate (or
due to higher oxygen demand and carbon dioxide for a full minute if irregular).
3. AMPLITUDE: production.
NCM101: HEALTH ASSESSMENT
B. AUSCULTATION: ADVENTITIOUS SOUNDS are abnormal breathing sounds
-​ Use a stethoscope to listen for adventitious (abnormal HYPOXIA - oxygen in the body lowers CUFF SIZE CONSIDERATIONS
breath sounds) breath sounds, such as crackles, FIBROMYALGIA - pain associated in muscles -​ The cuff bladder should encircle at least 80% of the arm.
wheezes (airway filled with air), or stridor(hukragong), -​ Using a cuff that's too small may result in falsely high
which can indicate respiratory problems. D. Blood Pressure (BP) readings, while a cuff that's too large may produce
BLOOD PRESSURE measures the force of blood against arterial falsely low readings.
C. INSPECTION: walls. It is expressed as systolic over diastolic pressure
-​ Assess for signs of respiratory distress, including the use Korotkoff Sounds
of accessory muscles(rise and fall of chest), nasal NORMAL RANGE: Phase 1: First faint tapping sounds (systolic pressure).
flaring(air hunger), cyanosis, or changes in posture SYSTOLIC: <120 mmHg. Phase II: Swishing or muffled sounds.
(e.g., tripod position). DIASTOLIC: <80 mmHg. Phase III: Distinct, louder sounds. I
-​ NORMAL: rise and fall of abdomen Phase IV: Sounds become muffled.
ABNORMAL: rise and fall of chest HYPERTENSION STAGES Phase V: All sounds disappear (diastolic pressure).
STAGE 1: 130-139/80-89 mmHg.
ABNORMAL RESPIRATORY PATTERNS STAGE 2: 2140/290 mmHg. Lifespan Considerations
➤ TACHYPNEA: -​ Older adults may exhibit orthostatic hypotension, a
-​ A rapid respiratory rate (greater than 20 breaths/min). FACTORS AFFECTING BLOOD PRESSURE sudden Bp drop when standing.
-​ can occur in conditions like fever, and respiratory PHYSICAL ACTIVITY: BP rises during exercise. -​ Pediatric BP is lower than in adults; use appropriate cuff
distress. STRESS: Sympathetic activation increases BP.
➤ BRADYPNEA: MEDICATIONS: Diuretics may lower BP; steroids can increase it. E. PAIN
-​ A slow respiratory rate (less than 12 breaths/min) BODY POSITION: BP is typically lower when lying down. PAIN is often referred to as the "fifth vital sign" and is assessed
-​ often due to central nervous system depression or drug CAFFEINE AND NICOTINE: Can cause a temporary rise in BP. using tools like the COLDSPA mnemonic:
overdose.
➤ APNEA: PROPER TECHNIQUE FOR MEASURING BP C: Character (What does the pain feel like?)
-​ absence of breathing. Prolonged apnea requires PREPARATION: O: On set (When did it start?)
immediate intervention as it can lead to hypoxia. -​ Ensure the client has rested for 5 minutes. L: Location (Where is the pain?)
➤ HYPERVENTILATION: -​ Avoid caffeine, nicotine, or exercise for 30 minutes D: Duration (How long does it last?)
-​ Increased rate and depth of breathing before measurement. S: Severity (How bad is it on a scale of 1-10?)
-​ often associated with anxiety, pain, or metabolic P: Pattern (What makes it better or worse?)
acidosis. POSITIONING: A: Associated factors (What other symptoms occur with the pain
➤ HYPOVENTILATION: -​ Sit the client with their back supported and feet flat on
-​ Decreased rate and depth of breathing the floor. CONCEPTUAL FOUNDATIONS OF PAIN
-​ commonly caused by sedation or neuromuscular -​ The arm should be at heart level, with the palm facing PAIN
dysfunction. upward. -​ a complex and subjective experience that involves
➤ Cheyne-Stokes Breathing: PROCEDURE: sensory, emotional, and cognitive components.
-​ Cycles of increasing and decreasing respirations with -​ Select the correct cuff size (detailed below). -​ generally defined as an unpleasant sensory and
periods of apnea -​ Palpate the brachial artery and position the cuff 1 inch emotional experience associated with actual or
-​ seen in heart failure, stroke, or end-of-life care. above the elbow. potential tissue damage or described in terms of such
➤ Kussmaul's Breathing Deep -​ Inflate the cuff 30 mmHg above the point where the damage.
-​ rapid breathing associated metabolic acidosis, such as radial pulse disappears. -​ serves as an important protective mechanism, alerting
in diabetic ketoacidosis -​ Slowly release the pressure (2-3 mmHg per second) the body to injury or illness.
while listening for Korotkoff sounds with a stethoscope.
NCM101: HEALTH ASSESSMENT
-​ can also become pathological leading to chronic -​ Pain signals are transmitted from thalamus to the -​ The body may tense muscles around the painful area in
conditions that significantly affect an individual quality somatosensory cortex, limbic system, and other areas an effort to protect it
of life. for processing.
C. PUPILLARY DILATION:
PERCEPTION OF PAIN is influenced by both physiological and 3. PERCEPTION -​ In response to pain, pupils may dilate as part of the
psychological factors. -​ the conscious experience of pain. fight-or-flight response.
-​ occurs when the brain processes the incoming pain
PAIN ASSESSMENT involves both self-reports from the patient and signals and identifies their location, intensity, and D. INCREASED BLOOD GLUCOSE LEVELS:
objective indicators, such as vital signs and behaviors. emotional significance. -​ Stress hormones can trigger the release of glucose to
provide energy for a potential fight or flight response.
PATHOPHYSIOLOGY OF PAIN CEREBRAL INVOLVEMENT: The thalamus acts as a relay station,
4 PROCESS OF PAIN PERCEPTION while somatosensory cortex interprets the pain's intensity and E: SWEATING:
1. TRANSDUCTION location -​ A common response to acute pain.
-​ the process by which a NOXIOUS STIMULUS (thermal,
chemical, or mechanical) is converted into an electrical. EMOTIONAL AND BEHAVIORAL RESPONSE: The limbic system and CHRONIC PAIN may lead to adaptive changes in these responses,
-​ Begins when pain receptors called nociceptors are cortex contribute to the emotional and cognitive aspects of pain causing persistent issues such as hypertension or insomnia.
activated tissue damage. perception.
CLASSIFICATIONS OF PAIN
NOXIOUS STIMULI: Can include heat, pressure, inflammation, or 4. MODULATION (can be categorized in several ways, based on its origin, duration,
chemical substances (e.g., prostaglandins, bradykinin, histamine) -​ refers to the process by which the body alters or adjusts and nature)
the perception of pain.
ION CHANNELS ACTIVATION: Tissue injury leads to the release of -​ involves descending pathways from the brain to the A. NOCICEPTIVE PAIN:
chemicals that activate nociceptors, resulting in changes in ion spinal cord, which can either amplify or inhibit pain -​ Caused by the activation of pain receptors due to
permeability and the generation of an action potential. signals. actual or potential tissue damage.
-​ includes somatic bain (from skin, muscles, bones, and
2. TRANSMISSION INHIBITORY NEUROTRANSMITTERS: Substances like endorphins, joints) and visceral pain from internal organs).
-​ the process by which the pain signal travels from the serotonin, and norepinephrine act as natural painkillers to reduce
site of injury to the brain via the nervous system. the intensity of pain. B. NEUROPATHIC PAIN:
-​ Resulting from damage to the nervous system itself.
3 STEPS OF TRANSMISSION: GATE CONTROL THEORY -​ may feel sharp, burning, or shooting and is often
1. PERIPHERAL NERVE FIBERS (First Order Neurons): -​ Proposed by Melzack and Wall, chronic.
-​ The action potential travels from the nociceptors -​ suggests that non-painful stimuli (eg, rubbing the
through A-delta fibers (sha localized pain) and C fibers injured area) "close the gate" in the spinal cord, blocking C. INFLAMMATORY PAIN:
(dull, throbbing pain) to the spinal cord the transmission of signals -​ Occurs when tissues are damaged and inflammatory
mediators are released, such as in conditions like
2. SPINAL CORD (Second Order Neurons): PHYSIOLOGIC RESPONSES TO PAIN arthritis.
-​ At the dorsal horn of the spinal cord, neurotransmitters A. SYMPATHETIC NERVOUS SYSTEM ACTIVATION:
(e.g., substance P, glutamate) relay the signal to the -​ Increased heart rate, blood pressure, and respiratory D. PSYCHOGENIC PAIN:
brainstem and thalamus. rate, as well as the release of stress hormones such as -​ influenced by emotional, psychological, or behavioral
cortisol and adrenaline. factors, though it may still have a physical basis.
3. BRAIN (Third Order Neurons):
B. MUSCLE TENSION AND GUARDING:
NCM101: HEALTH ASSESSMENT
OTHER CLASSIFICATIONS OF PAIN ACCORDING TO DURATION AND
LOCATION

ACUTE PAIN:
-​ Lasts for a short time and typically resolves once the
underlying cause is treated or healed.
-​ often has a clear cause, such as an injury or surgery

CHRONIC PAIN:
-​ Persists beyond the expected healing time, of 3 months
or more
-​ may be associated with ongoing conditions such as
arthritis, diabetes, or fibromyalgia.

BY LOCATION:

SOMATIC PAIN:
-​ Originates from skin, muscles, or joints
-​ typically localized and described as aching, throbbing,
or sharp

VISCERAL PAIN:
-​ Arises from internal organs and is often more diffuse.
-​ usually described as deep, squeezing, or cramping and
can be referred to other areas of the body.

REFERRED PAIN
-​ Pain that is felt in a different location from the site of
injury or damage, often seen in conditions such as heart
attacks (pain may be referred to the arm or jaw).

PSYCHOSOCIAL FACTORS AFFECTING PAIN PERCEPTION AND