HEALTH ASSESSMENT (Physical

Examination and History Taking) – LAB / RLE

STUDENT’S ACTIVITY SHEET BS NURSING / FIRST YEAR
Session # 9

LESSON TITLE: BEGINNING THE PHYSICAL Materials:

EXAMINATION: GENERAL SURVEY, VITAL SIGNS AND
Book, pen and notebook, index card/class list,
PAIN (2)
speaker and LCD projector
LEARNING OUTCOMES:
At the end of the lesson, the nursing student can: References:
Hogan-Quigley, B., Palm, M. L., & Bickley, L. S.
1. Perform initial pain assessment on a classmate or an adult
(2017). Bates' nursing guide to physical examination
patient using different pain assessment tools and history taking. Philadelphia: Wolters Kluwer.
2. Compare acute pain behaviours from chronic pain
behaviours. Udan, J. (2009). Health assessment and physical
3. Make an accurate documentation on pain assessment examination (1st ed.). Ermita manila,
4. Discuss other pain assessment tools including tools for Philippines: Educational publishing house
pediatric patients.

SUBJECT ORIENTATION (5 minutes)

To the students: Recapitulate the previous lessons: General Survey and Vital signs

MAIN LESSON (60 minutes)

The instructor should discuss the following topics. Instruct the students to take down notes and read their book about this
lesson. Please refer to Chapter 7: BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS
AND PAIN, page 138-142

PAIN ASSESSMENT: THE FIFTH VITAL SIGN

The patient’s self – report Pain – is a sensation of physical or mental hurt or suffering that causes distress or agony to the
one experiencing it.
 It is whatever the patient says it is.
 It exists whenever the patient says it does.
 It is a subjective in nature. Only the person experiencing it may describe it.
 It is a protective because it provides warning signal for tissue injury. It helps minimize injury and is often a
protective injury – prevention mechanism.
(For detailed explanation and examples, please refer to pages 138-142

Theories of pain
1. Pattern theory – it states that pain is perceived whenever the stimulus is intense enough.
2. Specificity theory – it states that there are specific nerve receptors for particular stimuli.
 Nociceptors – for noxious stimuli
 Thermoreceptors – heat or cold
 Mechanoreceptors – pressure, pulling or tearing sensation
 Chemoreceptors – for chemicals.
3. Gate control theory – it conceptualizes that there is a gate in the spinal cord called SUBSTANTIA
GELATINOSA. When the gate is open, pain stimulus is transmitted; thus, pain is perceived. When the gate is
close, pain stimulus is blocked; thus, no pain is perceived.
4. Affect theory- at avers that the pain is emotional. The intensity of pain perceived depends on the value of the
organ affected to the individual.

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 5. Parallel processing theory – it believes that the physiologic or neurologic deciphering of the pain sensation and
the cognitive emotional properties occur along different nerve fibres.

Factors influencing the Pain experiences Terms

 Age
 Sex  Pain threshold – the minimum amount of pain stimulation a person
 Childhood requires before feeling pain. Generally uniform amongst people.
 Cultural background
 Psychological factors  Pain tolerance – the maximum amount and the duration of pain
 Previous experience that an individual is willing to endure. It varies amongst people
 Religious beliefs
 Expected response  Pain perception – the actual feeling of pain.
 Setting
 Diagnosis  BRADYKININ – the universal stimulus for pain
 Physical / mental health
 Knowledge/ understanding  Hyperalgesia – excessive sensitivity to pain.

TYPES OF RESPONSES TO PAIN

Involuntary response – physiologic responses are Voluntary response
mediated by the ANS. a. Behavioural responses
e.g. crying, moaning,grimacing, tossing in bed, splinting the
NB: if the pain is mild to moderate, it is manifested by painful area, assuming fetal position.
SNS; whilst, if the pain is severe it is manifested by PNS. b. emotional responses
e.g. depression, withdrawal and social isolation

 CLASSIFICATION OF PAIN

Cutaneous or superficial pain It occurs over the body surfaces or skin segment

Somatic pain May be deep or superficial

It occurs in the skin, muscles or joints

Visceral pain It arises from stimulation of pain receptors in the abdominal cavity and the thorax.

Referred pain The pain is perceived at an area other than the site of injury.

Intractable pain It is resistant to any cure or relief.

Phantom pain Is actual pain felt in a body part that is no longer present.
E.g. pain experienced after the amputation of a limb.

Radiating pain It is felt at the source and extends to the surrounding tissues.

Psychogenic pain It is primarily due to emotional factors, with no physiologic basis.

Intermittent pain Pain that stops and starts again.

 LOCATION
This provides information on the organ affected,
e.g. left chest RUQ of the abdomen.

 DURATION
a. Acute pain. Lasts for less than 6 mons.
b. Chronic pain. Lasts for more than 6 mons.

 CHARACTER / QUALITY
Whatever description the client gives, accept it as it is. E.g., pricking, stabbing, dull throbbing.

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  INTENSITY / SEVERITY
Use scale of 0-10. 0 no pain, 1-3 mild, 4-6 moderate and 7-10 severe.

 RELIEVING FACTORS / AGGREVATING FACTORS

e.g. chest pain in angina pectoris can be relieved by rest or nitroglycerin

 EFFECTS TO ADLS
e.g. the pain in a client with herniated nucleus pulposus which can no longer be relieved by medications may
require surgery.
INITIAL PAIN ASSESSMENT
Where is your pain?  Pain may be localized or occurring in multiple sites.
When did your pain start?  Identifies onset and duration. Chronic pain is one that occurs for 6 months or
longer. Acute pain is one that occurs for less than 6 months.
What does your pain feel  Burning, stabbing, aching
like?  Throbbing, knife-like, squeezing
 Cramping, sharp, itching, tingling
 Shooting, crushing, sharp, dull
 Identifies quality of pain and helps differentiate between nociceptive and
neuropathic pain mechanisms.
 Neuropathic pain is described as burning, shooting and tingling.
 Nociceptive pain is originating from visceral sites and describes as aching if
localized and cramping if poorly localized.
 From somatic sites (muscles, bones, joints, tendons, blood vessels), it is
described as throbbing, aching
How much pain do you have  Identifies intensity
now?

PQRSTU PAIN ASSESSMENT

P – PROVOCATIVE / PALLIATIVE What brings it on?
What were you doing when you first noticed it?
What makes it better? Worse?
Q – QUALITY / QUANTITY How does it feel?
How intense/ severe is it?
R – REGION / RADIATION Where is it?
Does it spread anywhere?
S – SEVERITY SCALE How bad is it (on scale of 1 to 10)
Is it getting better or worse, or staying the same?
T - TIMING ONSET: exactly when did it first occur?
DURATION: how long did it last?
FREQUENCY: How often does it occur?
U – UNDERSTANDING patient’s What do you think it means? How does it affect your daily activities?
perception of the problem

Alternatively, OLD CART may also use as another means to assess PAIN, please refer to page 45 of your book.

PAIN ASSESSMENT TOOL

Various tools have been developed to assess uni-dimensional aspects (e.g., intensity) and multidimensional components
of pain.
In the initial Pain assessment, the nurse asks the patient to answer eight questions concerning location, duration, quality,
intensity and aggravating / relieving factors. In addition, the nurse adds questions about manner of expressing pain and
the effects of pain that impairs one’s quality of life.
PAIN RATING SCALES are uni-dimensional and are intended to reflect pain intensity. Numeric rating scales ask the
patient to choose a number that rates the level of pain, with) being no pain and the highest score 10 – indicating the worst
pain.

APPLICATION:
Instructions: Obtain an initial pain assessment on a classmate or patient using the Initial Pain Assessment tool

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INFANTS AND CHILDREN
They are incapable of “Self – report” on pain, but it is important to remember that infants do feel pain.
Children 2 years of age can report pain and point to its location. However, they cannot rate pain intensity at this
developmental level.
Rating scales can be introduced at 4-5 years old. The WONG – BAKER FACES Pain Rating Scales is one example. The
child is asked to choose a face that shows, “How much hurt you have now?”

CHECK FOR UNDERSTANDING (25 minutes)

The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.
Multiple Choice and short answer
(For 1-10 items, please refer to the questions in the Rationalization Activity)

1. Which of the following factors is most reliable indicator of pain in an adult patient?
a. Changes in physical functioning.
b. Nonverbal behaviours.
c. The patient’s self-report.
d. Changes in the vital signs
C
ANSWER: ________
RATIONALE:______________________________________________________________________________________
Option C, Self report remains the most reliable indicator of pain, even for patients with wild cognitive
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impairement.
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2. Which of the following measurement is incorrect about pain?

a. Pain exists whenever the patient says it does.
b. Pain is always accompanied by changes in the vital signs.
c. Pain is whatever the patient says it is.
d. Pain protects a patient from injury.
ANSWER: ________
D
RATIONALE:______________________________________________________________________________________
Option D, there are two types of pain voluntary and involuntary response.
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3. While examining a broken arm of a 4 –year- old boy, which of the following is the appropriate assessment
tool to evaluate his pain status?
a. 0-10 numeric rating scale
b. The Wong – Baker Scale
c. 0 – 5 Numeric rating Scale
d. Simple descriptor scale
B
ANSWER: ________
Option B, is the correct answer
RATIONALE:______________________________________________________________________________________
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4. Which of the following statements is true about pain in infants?

a. Infants do not remember pain.
b. Infants can report pain
c. Infants do feel pain
d. Infant’s pain may be assessed by using the Wong – Baker’s Face Pain Rating Scale.
C
ANSWER: ________

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 Option C, pain is a sensation of physical or mental hurt or suffering that causes distress or agony to the one
RATIONALE:______________________________________________________________________________________
experiencing it.
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5. To assess the SITE of pain, which of the following questions should be asked by the nurse?
a. Where is your pain?
b. When did your pain start?
c. How much pain do you have now?
d. What makes your pain better?
ANSWER: ________
Option A
Pain is sensation of physical or mental hurt that is why asking the patient where the pain is the question
RATIONALE:______________________________________________________________________________________
the nurse should ask.
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6. The pain that originate from muscle, bones, joints, tendons or blood vessels is known as:
a. Cutaneous pain
b. Referred pain
c. Visceral pain
d. Somatic pain
D
ANSWER:________
RATIONALE:______________________________________________________________________________________
Option D, is the correct answer.
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Referred pain is described as:

a. Originating from internal organs such as the gallbladder or stomach
b. Originating from skin or subcutaneous structures.
c. Felt at a particular site, but originates from another location.
d. Felt at the site of injury and the surrounding areas.
C
ANSWER: ________
RATIONALE:______________________________________________________________________________________
Option C, the pain is percieved at an area other than the side of injury
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8. You are a nurse in a medical emergency room and caring a 23-year-old female. As you are assessing, she
complained that she had “burning sensation during urination”. This is an example of:
a. Provocative / Palliative
b. Quality/ Quantity
c. Region / Radiation
d. Timing
B
ANSWER: ________
RATIONALE:______________________________________________________________________________________
Option B is the correct answer
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9. It describes the maximum amount and the duration of pain that an individual is willing to endure. It varies
amongst people
a. Pain receptor
b. Pain threshold
c. Pain tolerance
d. Pain sensation
C
ANSWER: ________
RATIONALE:______________________________________________________________________________________
Option C, Pain tolerance refers to how much pain a person can reasonably handle.
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10. You are a nurse working in a surgical ward and caring for a 53-year-old man who had an above the knee
amputation in his right leg. He complained of severe pain from his right lower leg. You are knowledgeable
that this is:
a. Intractable pain

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 b. Phantom pain
c. Psychogenic pain
d. Radiating pain
B
ANSWER: ________
Option B, is the correct answer.
RATIONALE:______________________________________________________________________________________
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RATIONALIZATION ACTIVITY (DURING THE FACE TO FACE INTERACTION WITH THE STUDENTS)
The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates.
1. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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2. ANSWER: ________
RATIONALE :__________________________________________________________________________________
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3. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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4. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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5. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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6. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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7. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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8. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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9. ANSWER: ________
RATIONALE:___________________________________________________________________________________
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10. ANSWER: ________

RATIONALE:___________________________________________________________________________________
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LESSON WRAP-UP (5 minutes)
Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.

CAT: Muddiest Point

The Muddiest Point

In today’s session, what was least clear to you?

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