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Chapter 9: Targeted Observation and Assessment

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the fundamental anatomy and physiology of pain.

-To list the different types of pain.

-To explain how to collect a health history in the assessment of a patient's pain.

-To explain how to complete a physical examination in the assessment of a patient's pain.

-To explain the concept of mental health and mental illness.

-To explain how to collect a health history in the assessment of a patient's mental health.

-To explain how to complete a physical examination in the assessment of a patient's mental health.

-To identify the risk factors for anxiety and depression.

-To recognise the different types of mental illnesses, and their typical presentation.

-To explain how to collect a health history in the assessment of a patient's nutritional status.

-To explain how to complete a physical examination in the assessment of a patient's nutritional status.

Fundamental anatomy and physiology of pain

Pain is experienced through a process known as nociception. Receptor cells referred to as nociceptors detect noxious, or pain-causing, stimuli. These nociceptors transmit the experience of the noxious stimuli, as an electrical impulse, to the brain. Electrical impulses are transmitted along nerve fibres with the assistance of neurotransmitters, particularly serotonin and noradrenaline. Once the electrical impulse reaches the brain, the brain can initiate a response to the pain. Pain is managed by using strategies to: (1) disrupt, or (2) block the transmission of pain-related electrical impulses to the brain.

There are many different types of pain. Pain is typically divided into: (1) nociceptive pain, associated with tissue damage, and (2) neuropathic pain, associated with nerve damage. Both types of pain may be: (1) constant, or (2) episodic. In addition, pain may also be classified as either: (1) acute, or (2) chronic. Read the information in the following table:

Acute Pain

Chronic Pain

Onset and Duration

  • Generally sudden onset.
  • Shorter-term duration.
  • Gradual or sudden onset.
  • Longer-term duration. 

Cause

  • A clearly-defined cause.
  • Cause may not be known, or may be unclear.

Course

  • Pain resolves as cause is addressed.
  • Pain may not resolve; may cycle through periods of improvement / worsening.

Goals of Treatment

  • Pain control and eventual elimination.
  • Pain control to the greatest extent possible; enhance function and quality of life.

Each individual person has a different pain threshold and a different pain tolerance. How pain is experienced, understood and responded to by an individual is dependent on a variety of personal and cultural factors.

Pain - focused health history

When assessing a patient's pain, the nurse must commence by collecting a health history. This involves collecting data about:

  • Present health status
    • Chronic illnesses
    • Current medications
  • Description of the pain
    • Onset
    • Provocation and palliation
    • Quality
    • Region and radiation
    • Severity
    • Time

Pain - physical examination

Once a health history of a patient's pain has been obtained, as described in the previous section of this chapter, a nurse may commence a physical examination of the patient to determine their response to the pain they experience:

  • Observe the patient for posture and behaviour.
  • Observe the patient's facial expression.
  • Listen for sounds made by the patient.
  • Inspect and palpate the patient's skin for colour, temperature, moisture.
  • Measure the HR and BP.
  • Assess RR and pattern.
  • Observe the pupillary size.

As you saw in a previous section of this unit, once a health history and physical examination have been completed, they should be documented so that the data collected can be used to: (1) assess the patient's condition, and (2) inform the care which is appropriate for that patient.

Mental health and wellbeing

The term 'mental health' is used to describe a person's state of mind, which impacts on their ability to cope appropriately with daily stressors. It is important for nurses to remember that there are a variety of internal and external factors which determine a person's mental health.

Mental health - focused health history

An assessment of a person's mental health is one of the few assessments where a nurse is not required to perform a physical examination of a client. This is because most of the data needed for the assessment of a person's mental health can be gathered during the health history, by talking with and observing the client.

When assessing a patient's mental health via a focused health history, a nurse should collect data about:

  • Present health status
    • Current feelings and emotions
    • Current medical problems
    • Current medications
    • Risk factors for mental illness
  • History of previous mental illness, and history of coping strategies
  • Family history of mental illness

When collecting information about a person's mental health, a nurse should carefully observe the patient. The nurse should determine how the client appears and behaves, their cognitive function, their alertness and their orientation to time, place and person. These observations can provide a nurse with important information about the patient's mental status.

It is important for nurses to note that there are a variety of score tools which may be used to assess a patient's risk of certain mental illnesses. When using score tools to assess a patient's risk of certain mental illnesses, it is important that nurses use critical thinking to interpret the entire clinical picture of the individual patient with whom they are working.

In some cases, a person will present with a specific problem related to their mental health (e.g. depression, anxiety, etc.). A nurse may therefore ask more focused questions:

If a patient presents with…

A nurse may ask about…

Symptoms of depression, low mood.

  • Risk factors for depression (see following).
  • Feelings of being low, down, hopeless, etc.
  • Feelings of disinterest, lack of pleasure, etc.
  • Feelings of anger, frustration, irritability, etc.
  • Feelings of needing to 'escape', of wanting to self-harm, etc.
  • Difficulty falling / staying asleep, lack of energy.
  • Change in appetite, unintentional weight gain / loss.
  • Difficulty concentrating, making decisions.
  • Frequency of these feelings.
  • The extent to which these feelings bother the client.
  • History of similar feelings, and coping mechanisms.
  • Level and type of social support.

Symptoms of anxiety.

  • Risk factors for anxiety (see following).
  • Feelings of anxiety, fear, terror, etc.
  • Feelings of anger, frustration, irritability, etc.
  • Feelings of needing to 'escape', of wanting to self-harm, etc.
  • Feelings of tenseness, nausea, other physical symptoms, etc.
  • Frequency of these feelings.
  • The extent to which these feelings bother the client.
  • History of similar feelings, and coping mechanisms.
  • Level and type of social support.

When collecting a health history from any patient, it is important that the nurse is aware of risk factors for depression and anxiety. These are listed in the following table:

Risk Factors for Depression

Risk Factors for Anxiety

  • Experience of a stressful life event.
  • Chronic illness.
  • Older age.
  • Personality type.
  • Family history of depression.
  • Giving birth.
  • Loneliness, social isolation.
  • Use of alcohol and drugs.
  • Over-activity of the areas of the brain involved in emotion / behaviour.
  • An imbalance of the neuro-regulators serotonin / noradrenaline in the brain.
  • Family history of anxiety disorder.
  • Stressful or traumatic experiences.
  • A painful chronic illness.
  • Use of alcohol and drugs.
  • Older age.

Although there is no physical examination specific to mental illness, it is important for a nurse to remember that the signs of mental illness may be identified during observation and physical examination of a client. The signs of mental illness may include:

  • Tense muscles, fidgeting, pacing, body tremors, perspiration; slumped posture.
  • Soiled clothing / lack of hygiene.
  • Changes in tone and rate of speech.
  • Loss of orientation to time / place / person; failure to remember details after reorientation.
  • The client has difficulty with word placement; cannot remember incorrect words.
  • The client names objects incorrectly; cannot comprehend a written phrase.
  • The client demonstrates a lack of judgement / reasoning.
  • The client has elevated BP, HR, RR.
  • The client's eye movements are rapid / uncoordinated.

Differential diagnosis of mental illness

When assessing a patient's mental health, there are a number of common problems and conditions a nurse may identify:

  • Depression
  • Generalised anxiety disorder
  • Panic disorder
  • Social phobia
  • Specific phobias
  • Obsessive-compulsive disorder
  • Post-traumatic stress disorder
  • Bipolar disorder
  • Schizophrenia
  • Dementia
  • Delirium

When assessing a person for mental illness, it is important for nurses to remember that drug and / or alcohol intoxication can closely mimic mental illness. It is also very common for drug and / or alcohol intoxication to occur in conjunction with mental illness. There are a variety of substances with which a person may be intoxicated:

  • Alcohol
  • Narcotics
  • Stimulants
  • Depressants
  • Hallucinogens
  • Club drugs
  • Inhalants
  • Prescribed medications

The symptoms of intoxication vary depending on the substance taken; however, typically a patient will usually present with changes in their level of consciousness, cognition, perception, affect, behaviour and motor coordination. It is also important for a nurse to remember that neurological illness and injury can mimic mental illness.

When assessing a person for mental illness, it is important for nurses to remember that mental illness is associated with much stigma in the United Kingdom. Stigma may make a patient reluctant to seek assessment or treatment for mental illness, it may cause them to be unwilling to accept the results of a mental health assessment, and it may result in their noncompliance with a treatment regimen.

Assessment of nutrition

Nutritional assessment is not typically performed in isolation; rather, it is one part of the broader general assessment. The nutrition assessment includes a focused health history, and a physical examination involving anthropometric measurements and biochemical tests.

Nutrition assessment - focused health history

When assessing a patient's nutritional status, the nurse must commence by collecting a health history. This involves collecting data about:

  • Present health status
    • Current illnesses
    • Current medications
    • Unexplained changes in weight in the previous 6 months
    • Food intolerances and / or allergies
    • Problems obtaining, preparing or consuming foods
    • Use of drugs and / or alcohol
  • Past medical / family history
    • Past concerns about weight / problems eating
    • Family history of nutritional problems

In some cases, a person will present with a specific problem related to their nutritional status.

When collecting a health history from a patient, it is important for a nurse to gather data about a patient's dietary intake. This usually involves a patient recalling and reporting their dietary intake over the course of one or several days, using one of the following techniques:

Technique

Description

24-hour recall

The client recalls everything they have consumed in the previous 24 hours.

Typical food intake

The client describes the foods / drinks they typically consume in a day.

Food diary

The client records everything they consume in a given period.

Food frequency questionnaire

The client indicates the frequency of intake of certain foods.

It is important for a nurse to realise that there are some limitations with these techniques to gather data about a patient's dietary intake. For example, it can be challenging for a patient to recall and report their intake accurately. Furthermore, such a 'snapshot' of a patient's nutritional intake may not reflect their actual intake over a longer period of time. A nurse should consider these limitations when using these techniques, and interpreting findings.

It is important that the nurse is aware of risk factors for common nutrition-related problems - including obesity, malnutrition and eating disorders. These are listed in the following table:

Risk Factors for Obesity

Risk Factors for Malnutrition

Risk Factors for Eating Disorders

  • High-fat diet.
  • Sedentary lifestyle.
  • Family history / genetics.
  • Ethnicity.
  • Older age.
  • Illness.
  • Some medications.
  • Hospitalisation, long-term residential care.
  • Low socioeconomic status.
  • Preoccupation with weight, appearance.
  • Perfectionism, high-achieving.
  • Low self-esteem, disturbed self-image.
  • Peer pressure.
  • Compulsive / binge-eating behaviour.

Nutritional assessment - physical examination

A nurse may then commence a physical examination to further investigate a patient's nutritional status:

  • Measure Body Mass Index (BMI), as described in an earlier chapter.
  • Assess the client's general appearance.
  • Inspect the skin surface or characteristics, hydration, lesions.
  • Inspect the hair and nails or appearance, texture.
  • Inspect the eyes for surface characteristics.
  • Inspect the oral cavity for dentition, intact mucous membranes.
  • Inspect and palpate the extremities for shape, size, coordinated movement, sensation.

It is important to note that a number of laboratory tests may be used in the nutritional assessment of a patient, including:

  • Serum albumin.
  • Haemoglobin.
  • Blood glucose.
  • Lipid profile.

Conclusion

This chapter has introduced the processes involved in the focused assessment of common issues which affect a number of the body systems concurrently: pain, mental health status and nutritional status. It described how to collect a health history, and complete a physical examination, when undertaking each of these types of focused assessments. This chapter also explained many key considerations when assessing a patient's pain, mental health status and nutritional status, including the anatomy, physiology and types of pain, the risk factors for common mental illnesses such as anxiety and depression, the types of mental illnesses and their typical presentation, and common nutritional disorders.


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