NURS 7110 - Module 2 Emergency
Nursing Framework Exam-Graded A
Visceral Pain - ANS-1. Tension Pain
2. Inflammatory Pain
3. Ischemic Pain
Tension Pain - ANS-Described by vague, deep, and poorly localized.
Causes of Tension Pain - ANS-- "Colic" - from increased force of peristaltic contraction
-Common when bowel is trying to pass irritating substances (spicy, lactose, infectious)
-Obstructions (tumors, adhesions, constipation etc)
- Increased inflammation to solid organs (spleen, liver, kidney etc)
- Gastroenteritis (d/t irritating foods or infection), constipation, and acute pancreatitis
(inflamed organ)
-Crohns/Colitis
-IBS
-Pyelonephritis
-Peptic Ulcer
-GERD
-Celiac Disease
Inflammatory Pain - ANS-Begins as deep and poorly to localize and inflammation of the
visceral peritoneum → initially perceived as vague, deep, difficult to localize, and may
be referred to a distinct site.
- Makes an effort to lie still - how to differentiate between tension and inflammatory
Common Causes of Inflammatory Pain - ANS--Appendicitis → initially pain is mid
abdominal or periumbilical then progresses into the parietal peritoneum, and then it is
more localized to the RLQ. And discomfort during palpation is a distinct feature.
-Cholecystitis
-Choleilithiases
-Urolithiasis
-Pancreatitis
-Ruptured Ectopic Pregnancy
-Pelvic Inflammatory Disease
-Perforated gastric or peptic ulcers
Ischemic Pain - ANS-Sudden onset, intense, continuous, and progressive, poorly
localized. Not relieved by analgesia
, Common Causes of Ischemic Pain - ANS-- Least common but most serious
- Strangulated bowel d/t obstruction is the most common cause
- Bowel Obstruction → tension pain then turns into ischemic pain
- Mesenteric artery infarct → d/t emboli or thrombus
-Sickle cell anemia
-Ruptured AAA
Associated Symptoms with Abdominal Pain - ANS-Gastrointestinal - Nausea, vomiting,
diarrhea, and if infection - fever & chills
Genitourinary - Urinary frequency and burning
Gynecological - Females who are sexually active - vaginal discharge and abdominal
periods
Musculoskeletal - Trauma? From assault or heavy lifting
Level Of Urgency (LOU) - ANS--Stable patients present with normal clinical findings and
a history leading to admission that is not life or limb threatening.
-Unstable patients present with abnormal clinical findings and a history that is
considered life or limb threatening.
-Potentially unstable patients may present with normal clinical findings but their history
leading to admission warrants concern and ongoing observation. Could deteriorate if
proper intervention is not taken. Considered for all stable patients.
Canadian Triage Acuity Scale (CTAS) - ANS-Level 1 - Resuscitation
Level 2 - Emergent
Level 3 - Urgent
Level 4 - Less-Urgent
Level 5 - Non-Urgent
Neurological Assessment - ANS-- Glascow Coma Scale (Eyes Open, Verbal Response,
Best Motor Response)
- Pupillary Response
- ROMS
- Limb Strength and equality
- Presence of drift
Respiratory Assessment - Insepct - ANS-- mental status/orientation
-general appearance
-client position to facilitate breathing
-color of skin, earlobes, nail beds, mouth, distal extremities
- presence of cough and expectorate (color, amount, consistency)
- rate, rhythm, and depth of breathing
- effort of breathing and use of accessory muscles
- deviation or tugging of trachea
- signs of injury
- deformities/scars of thorax or spine
Nursing Framework Exam-Graded A
Visceral Pain - ANS-1. Tension Pain
2. Inflammatory Pain
3. Ischemic Pain
Tension Pain - ANS-Described by vague, deep, and poorly localized.
Causes of Tension Pain - ANS-- "Colic" - from increased force of peristaltic contraction
-Common when bowel is trying to pass irritating substances (spicy, lactose, infectious)
-Obstructions (tumors, adhesions, constipation etc)
- Increased inflammation to solid organs (spleen, liver, kidney etc)
- Gastroenteritis (d/t irritating foods or infection), constipation, and acute pancreatitis
(inflamed organ)
-Crohns/Colitis
-IBS
-Pyelonephritis
-Peptic Ulcer
-GERD
-Celiac Disease
Inflammatory Pain - ANS-Begins as deep and poorly to localize and inflammation of the
visceral peritoneum → initially perceived as vague, deep, difficult to localize, and may
be referred to a distinct site.
- Makes an effort to lie still - how to differentiate between tension and inflammatory
Common Causes of Inflammatory Pain - ANS--Appendicitis → initially pain is mid
abdominal or periumbilical then progresses into the parietal peritoneum, and then it is
more localized to the RLQ. And discomfort during palpation is a distinct feature.
-Cholecystitis
-Choleilithiases
-Urolithiasis
-Pancreatitis
-Ruptured Ectopic Pregnancy
-Pelvic Inflammatory Disease
-Perforated gastric or peptic ulcers
Ischemic Pain - ANS-Sudden onset, intense, continuous, and progressive, poorly
localized. Not relieved by analgesia
, Common Causes of Ischemic Pain - ANS-- Least common but most serious
- Strangulated bowel d/t obstruction is the most common cause
- Bowel Obstruction → tension pain then turns into ischemic pain
- Mesenteric artery infarct → d/t emboli or thrombus
-Sickle cell anemia
-Ruptured AAA
Associated Symptoms with Abdominal Pain - ANS-Gastrointestinal - Nausea, vomiting,
diarrhea, and if infection - fever & chills
Genitourinary - Urinary frequency and burning
Gynecological - Females who are sexually active - vaginal discharge and abdominal
periods
Musculoskeletal - Trauma? From assault or heavy lifting
Level Of Urgency (LOU) - ANS--Stable patients present with normal clinical findings and
a history leading to admission that is not life or limb threatening.
-Unstable patients present with abnormal clinical findings and a history that is
considered life or limb threatening.
-Potentially unstable patients may present with normal clinical findings but their history
leading to admission warrants concern and ongoing observation. Could deteriorate if
proper intervention is not taken. Considered for all stable patients.
Canadian Triage Acuity Scale (CTAS) - ANS-Level 1 - Resuscitation
Level 2 - Emergent
Level 3 - Urgent
Level 4 - Less-Urgent
Level 5 - Non-Urgent
Neurological Assessment - ANS-- Glascow Coma Scale (Eyes Open, Verbal Response,
Best Motor Response)
- Pupillary Response
- ROMS
- Limb Strength and equality
- Presence of drift
Respiratory Assessment - Insepct - ANS-- mental status/orientation
-general appearance
-client position to facilitate breathing
-color of skin, earlobes, nail beds, mouth, distal extremities
- presence of cough and expectorate (color, amount, consistency)
- rate, rhythm, and depth of breathing
- effort of breathing and use of accessory muscles
- deviation or tugging of trachea
- signs of injury
- deformities/scars of thorax or spine
