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NUR455 Exam 2
| Question | Answer |
|---|---|
| Nociception Pain | Physiological Pain |
| Nociception Pain Process | Transduction (stimuli activates primary afferent neurons) Transmission (signal travels to brain via spinal cord) Perception (brain receives & processes) Modulation (how body alters brain signal) |
| Opioid Tolerance | normal response with regular use of opioid; decrease in one more of the effects; increased usage needed to effect pain relief |
| Opioid Physical Dependence | (addiction): normal response with opioid use of 2+ weeks; manifested by withdrawal symptoms Intervention: wean them off |
| Pain Assessment Collection Data | P: precipitating/alleviation factors Q: quality of pain R: region and radiation S: severity T: timing |
| Pain Assessment Collection Data Additional Considerations | Determine the pain goal, how it affects their social life, how does it affect their family, co-morbidities, previous measures to decrease pain, present pain, and interventions (LOC, abilities to do stuff, proper judgements, timely reactions) |
| Pain Relief Measurement Considerations | LOC Abilities to do daily activities (drive, operate machinery, etc.) Proper judgements Timely reactions |
| Non-pharmacological/alt. Pain Relief Measures Education | These are all in addition to their pain already in place; do not take away from their pain pharm methods They need to be aware that they must speak to their provider, especially with natural products |
| Natural Pain Relief Products | herbs, botanicals, vitamins, & probiotics |
| Physical Pain Relief Methods | acupuncture, chiropractic manipulation, massage therapy, TENS unit, physical therapy, heat/cold |
| Cognitive/Behavior Pain Relief Methods | breathing, music, guided imagery, meditation, and hypnosis |
| Energy Pain Relief Methods | yoga, tai chi, Reiki |
| PCA Education: Acute Care Setting | Push the button to administer medication before the pain gets above a 6 Don’t let friends/family members push the button for you The pump won't let you administer too much medication |
| Acute Pain Considerations | results from temporary act (trauma, surgery, illness). Short-term. Sudden onset & disappearance |
| Chronic Pain Considerations | lasts months, yrs, or lifetime. Constant or intermittent. Cancer is common. Also joint pain, neuropathy. Can have acute pain and chronic pain together. How pain affects caregiver & patient Resource available to patient to management pain outside |
| Breakthrough Pain Considerations | PRN medications |
| New Occurrence of Acute Pain for Patients w/ Chronic Pain Considerations | New injury—if the patient has chronic pain but comes in with acute pain, it will be more difficult to manage because they might have a tolerance due to their regular use of pain medication |
| Neuropathic Pain Management | pathologic pain. Multiple types of pain at the same time & in the absence of tissue damage & inflammation |
| Cause of Neuropathic Pain | Abnormal processing of sensory input through central/peripheral nervous system to one or both systems; results from damage/dysfunction. Causes hypersensitivity systemically Pain threshold becomes diminished |
| Older Population Pain Management Considerations | Sensitivity to agents that produce sedation and CNS effects Initiate with low dose and titrate slowly Increased risk for NSAID-induced GI toxicity Acetaminophen preferred for mild pain Opioid dose should be reduced 25-50% |
| Rheumatoid Arthritis | Affects females 2x more than males Onset occurs between 30-60 y/o |
| RA Stages | Early Moderate Persistent Advanced |
| RA Pathophysiology | Starts in synovial tissue (generally in the distal tissues of hands, fingers, and toes) > breaks down collagen > creates edema >proliferation of synovial membranes > pannus membranes (crackly grape looking) > symmetric joint pain & stiffness |
| RA S/S | morning stiffness lasting for more than an hour; swelling of joints; redness, lack of joint function |
| Additional Possible S/S of RA | fever, weight loss, enlarged lymph nodes; weight loss; Reynaud’s phenomenon, anemia |
| RA Diagnostic Tool | DAS28 (Disease Activity Score in 28 Joints) used to review severity and progression |
| RA Pharmacological Treatments | Early RA: NSADs Moderate: NSAIDs Persistent: NSAIDs, corticosteroids Advanced: NSAIDs, corticosteroids, immunosuppressive agents |
| RA Non-Pharmacological Treatments | Early RA: DMARD therapy; will start to feel better as early as 6 weeks Moderate: DMARD, OT, PT Persistent: DMARDS, OT, PT, Reconstructive Surgery Advanced: -- |
| SLE | Systemic Lupus Erythematous |
| Lupus Clinical Manifestations | fever, anorexia, malaise, weight loss, joint pain, tenderness |
| Nursing Management of Lupus | Emotional: help patients w/ self esteem issues, the stress of living w/ chronic disease. Coping: help pt develop coping strategies to deal w/ fatigue & stress of new disease. Educate pt to have adequate rest periods after activities |
| Lupus Pathophsyiology | Affects nearly every organ in the body Occurs 6-10x more females than males More common in AA Body immune system identifies cell’s nucleus as foreign > antibodies develop > starts attack cell’s nucleus as if it were an antigen Thought to be trigger |
| Lupus Diagnosis (must have 4/11) | Mallard rash—butterfly rash Discoid rash Photosensitivity Non-erosive arthritis Oral lesions Kidney disease Pericarditis—common cardiac issue Neurologic disease Hematologic disorder Immunologic disorder Positive A&A (Antinuclear Antibody) |
| Scleroderma | A connective tissue disease that affects the skin, internal walls, blood vessel walls; can be localized or systemic; affects women 3-5x more than men; occurs 30-50 y/o |
| Scleroderma S/S | skin becomes hard/rigid; extremities will stiffen over time; shiny skin; hair loss; pulmonary hypertension; hardening of internal organs |
| Scleroderma CREST Syndrome | Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangiectasia |
| Polymyalgia Rheumatica | HLA-DR4 can be blamed for it but the patho is unknown Immunoglobulin deposit in the walls of inflamed temporal arteries suggest AI response |
| Polymyalgia Rheumatica S/S | Severe proximal muscle discomfort Joint swelling Aching in neck, shoulder, and pelvic muscles Low-grade fever Significant weight loss, anorexia, depression, malaise |
| Polymyalgia Rheumatica Treatment | NSAID’s + corticosteroids |
| Giant Cell Arteritis | inflammation of lining of your arteries |
| Giant Cell Arteritis Diagnosed | ESR: erythrocyte sedimentation rate; indirect measure of inflammation CRP: C-reactive protein produced by liver cell; direct measure of inflammation 88-98% making a diagnosis if these two come back positive + clinic findings |
| Giant Cell Arteritis S/S | Changes in vision Headache Jaw claudication (difficulty moving jaw) Sudden/permanent loss of vision |
| Giant Cell Arteritis Treatment | Corticosteroids NSAIDs |
| Gout Pathophysiology (OA) | caused by hyperuricemia > uric acid turns to crystals to form in joint space > tophi |
| Gout Treatments | Colchine NSAID (for attacks) Allopurinol/febuxostat for maintenance; they need to get their labs checked |
| Gout Medications Side Effects | Suppress bone marrow |
| Gout Medications Potential Complications | Thrombocytopenia |
| Degenerative Joint Disease (OA) | Articular cartilage breaks down > progressive damage to underlying bone > formation of bone spurs ? protrudes into joint space > decreasing joint movement > damage Primary or secondary; weight-bearing joints NOT r/t autoimmunity or inflammation |
| Degenerative Joint Disease (OA) Risk Factors | old age female obesity |
| Degenerative Joint Disease (OA) S/S | Pain, stiffness, functional impairment, stiffness lasting LESS than 30 minutes |
| Degenerative Joint Disease (OA) Treatment | exercise |
| Rheumatic Disease | Most commonly manifest the clinical features of arthritis (inflammation of a joint) and pain Marked by periods of remission and exacerbation Organ failure and death |
| Rheumatic Disease Classification | Monoarticular or polyarticular Inflammatory or noninflammatory |
| Rheumatic Disease S/S | pain, sleep disturbances, deformity, stiffness lasting longer than an hour |
| Rheumatic Disease Pathophysiology | Inflammation: complex process resulting in pannus Autoimmunity: hallmark of rheumatologic disease; body recognizes ow n tissue as foreign Degeneration: secondary process to inflammation |
| Scleroderma CREST Syndrome (continued) | C-calcium skin deposits R-vessels of fingers & toes span triggered by cold/stress/illness. Esoph dysmotility S-thicken & tighten finger skin T-dilated/broken vessels near surface; fine pink/red lines, blanch when pressed |
| Sprains | injury to a ligament and supporting muscle fiber around the joint-Joint is tender, movement is painful, edema, disability and pain increases during the 1st 2-3 hours. |
| Strains | pulled muscle injury to the musculotendinous unit. Pain, edema, muscle spasms, ecchymosis, and the loss of function are on a continuum |
| Strain Classifications | 1st degree 2nd degree 3rd degree |
| Strain 1st Degree | mild stretching of the muscle/tendon w/ no loss of range of motion (ROM) S/S: gradual onset of palpation-induced tenderness & mild muscle spasm |
| Strain 2nd Degree | moderate stretching and/or partial tearing of muscle/tendon S/S: acute pain during precipitating event, followed by tenderness at site w/ increased pain w/ passive ROM (PROM), edema, significant muscle spasm, & ecchymosis. |
| Strain 3rd Degree | severe muscle/tendon stretching w/ rupturing & tearing of involved tissue. S/S: immediate pain described as tearing/snapping/burning, muscle spasm, ecchymosis, edema, & loss of function. |
| Strain 3rd Degree Diagnostic Considerations | obtain x-ray to rule out bone injury, because an avulsion fracture may be assoc w/ a 3rd degree strain X-rays do not reveal injuries to soft tissue/muscles/tendons/ligaments, but MRI & ultrasound can identify these injuries |
| Avulsion Fracture | bone fragment is pulled away from the bone by a tendon |
| Sprains & Strains Treatment | Protect from further injury (sling/splint) Rest Ice Compression bandage Elevate guided by the severity |
| Benefits of Icing | Cold in first 24-72 hrs after injury produces vasoconstriction, which decreases bleeding, edema, & discomfort. Cold packs should not be in place for longer than 20 min at a time Avoid skin & tissue damage from excessive cold |
| Benefits of Compression Bandages | controls bleeding, reduces edema, and provides support for the injured tissues |
| Benefits of Elevation | at or just above the level of the heart controls the swelling |
| Sprain/Strain Considerations | If the sprain or strain is third degree, immobilization by a splint, brace, or cast may be necessary so that the joint will not lose its stability NSAIDs for pain |
| Neurovascular Status of Strains/Sprains | monitored at frequent intervals (Q15min first 1-2 hrs), then lesser intervals (Q30min) until stable. < in sensation/motion & > in pain level should be doc & reported immediately to avoid compartment syndrome |
| Neurovascular Status | circulation motion sensation |
| Hip Fractures Risk Factors | over 65 years of age |
| Hip Fracture Precautions | Maintain neutral hip position isometric exercises, quad setting and gluteal setting exercises use trocanter rolls maintain hip abduction use ambulatory aids consult physical therapist use trapeze |
| Hip Fracture Precautions 2 | bend no more than 90 degrees at waist/hip area no bend over for shoes/socks/pants good nutrition: protein. adequate fluids, deep breath & cough ankle exercises participation in self care educate family safety, fall prevention & education |
| Hip Fracture Nursing Interventions: Repositioning | most comfortable & safest way to turn pt=turn to uninjured side. Standard method involves placing a pillow between the pt’s legs to keep affected leg in abducted position. Proper alignment & supported abduction are maintained while turning. |
| Hip Fracture Nursing Intervention | Repositioning Promoting exercise Monitoring & Managing Prevent VTE Education Lung Complications Skin breakdown Urinary health |
| Hip Fracture Nursing Interventions: Promoting Exercise | exercise as much as possible by means of the over the bed trapeze. On the first postoperative day, the patient transfers to a chair with assistance and begins assisted ambulation. |
| Hip Fracture Nursing Interventions: Monitor & Manage | potential complications-With hip fracture, bleeding into the tissues and edema are expected. Monitoring and documenting the neurovascular status of the affected leg are vital. |
| Hip Fracture Nursing Interventions: Prevent VTE | encourages intake of fluids and ankle and foot exercises. Anti Embolism stockings, pneumatic compression devices, and prophylactic anticoagulant therapy are indicated and should be prescribed |
| Hip Fracture Nursing Interventions: Education | should be done to teach signs and symptoms of DVT to patients and family |
| Hip Fracture Nursing Interventions: Pulmonary Complications | atelectasis/pneumonia=threat to older pts for hip surgery. Cough & deep breath intermittent changes of position incentive spirometer. Treat pain w/ analgesic agents, typically opioids. Assesses breath sounds to detect adventitious/diminished |
| Hip Fracture Nursing Interventions: Skin Breakdown | Nonelastic tape pulls on soft tissue causing blisters Pts w/ hip fractures remain in one position=devel pressure sores Proper skin care helps relieve pressure. High-density foam mattress overlays provide protection by distributing pressure evenly. |
| Hip Fracture Nursing Interventions: Urinary Retention | common after surgery, the nurse must assess the patient’s voiding patterns. To ensure proper urinary tract function, the nurse encourages liberal fluid intake if the patient has no pre-existing cardiac disease. |
| Amputation | done at the distal most point that will heal successfully. |
| Amputation Reasons | relieve symptoms, increase function & improve quality of life |
| Amputation: Syme | (modified ankle disarticulation amputation)=performed most frequently for extensive foot trauma and aims to produce a durable residual limb that can withstand full weight bearing. |
| Amputation: Syme Pt Education - Mobility Post-Surg | must use assistive devices & physical therapy until they can use the prosthetic comfortably ROM exercises muscle strengthening exercises proper positioning of the limb frequent turing prosthetic care |
| Fracture Types | Compression Compound Impacted Transverse Greenstick |
| Fracture: Compression | bone has been compressed, causing many tiny fractures, usually happens in the vertebrae |
| Fracture: Compound | open fracture, breaks through the skin. most dangerous because of risk for infection and bleeding |
| Fracture: Impacted | bone fragment is driven into another bone fragment |
| Fracture: Transverse | broken straight across the bone shaft |
| Fracture: Greenstick | usually happens in young children, one side of the bone is broken and the other side is bent |
| Fracture Complications | Compartment syndrome Fat embolism Avascular necrosis of bone Complex regional pain syndrome |
| Fracture Complications: Compartment Syndrome Patho | > pressure in anatomic compartment (> than normal perfusion pressure). Usually occurs in large bone fractures. > in compartment volume & > edema from fluid displacement & bleeding or a reduction in space from cast that is too tight. |
| Fracture Complications: Compartment Syndrome Effects | decreased perfusion & cell death |
| Fracture Complications: Compartment Syndrome S/S | Up to 48 hrs to present. and happens suddenly medical emergency@! sudden unrelenting pain & throbbing, that medication will not help. |
| Fracture Complications: Fat Embolism Patho | usually occurs in fracture of large bone like the femur. Happens most often in young adults. Can happen in older adults if they break their hip and fracture the proximal femur and socket. |
| Fracture Complications: Fat Embolism S/S | sudden onset of respiratory distress, dyspnea, tachycardia, hypoxia, pyrexia, anxious, chest pain, productive cough with white thick sputum and wheezing. early fixation can help prevent this from happening. |
| Fracture Complications: Avascular Necrosis of Bone Patho | blood supply to the bone decreases and the bone starts to die. happens most frequently in patients with rheumatoid arthritis, radiation therapy, corticosteroid therapy and sickle cell disease. |
| Fracture Complications: Avascular Necrosis of Bone Treatment | exercises, NSAIDS and removing the diseased part of the bone |
| Fracture Complications: Avascular Necrosis of Bone S/S | pain with movement that progresses to pain at rest |
| Fracture Complications: Complex Regional Pain Syndrome | rare, happens more in women. consists of chronic pain after an injury has healed |
| Fracture Complications: Complex Regional Pain Syndrome S/S | edema, burning pain, stiffness, and discoloration |
| Fracture Complications: Complex Regional Pain Syndrome Treatment | rehabilitation, pain management and referral to mental health |
| Classifications of Burns | 1st Superficial 2nd Partial & Intermediate Thickness 3rd Full Thickness 4th Deep |
| Classifications of Burns: 1st Degree | Only involves outermost layer of skin. Pain, no scarring, no blisters |
| Classifications of Burns: 2nd Degree Partial | No surgery, no scarring, more pain. Yes, blisters, weeping. More depth = more risk of infection & scarring Has hair |
| Classifications of Burns: 2nd Degree Intermediate | needs surgery. More scarring. Less pain. Yes, blisters & weeping. High infection. Has hair |
| Classifications of Burns: 3rd Degree Full | Dry, numbness. Yes, scarring. High infection risk. Pain in area immediately outside burn area. No hair - destroyed |
| Classifications of Burns: 4th Degree Deep | muscle or bone. Leads to loss of the burned part |
| TBSA | Total Body Surface Area |
| TBSA 3 Methods | Rule of Nines Lund & Browder Method Palmer Method |
| TBSA 3 Methods: Rule of Nines | most common for adults (not used for children), goes by anatomical regions. Each region is basically 9% |
| TBSA 3 Methods: Lund & Browder Method | uses % of TBSA of anatomic parts also. More precise. Perform at admission & 72 hrs later (because true burn extent hard to tell when so much edema is involved & takes 72 hrs to decrease) |
| TBSA 3 Methods: Palmer Method | used to estimate extent of scattered burns. Typically chemical. Provider uses palm of hand to measure 1% of TBSA |
| Chemical Burns | heat transfer from one side to another |
| Thermal Burns | includes electrical, skin and mucosa of upper airway most common site |
| Radiation Burns | threat of terrorism is thermal and destroys DNA |
| Major Burn Effects on Fluid & Electrolytes | hypovolemia & shock. Decreased perfusion & less oxygen delivery. General dehydration occurs. Less urinary output initially. (potassium highest inside cell, which if damaged will leak out). Low sodium. Metabolic acidosis. |
| Major Burn Effects on Cardiovascular Status | as output lessens, fluid lessens & causes BP to drop Fluid lost due to capillary leakage Body responds by inflammatory response (vasoconstriction -> vasodilation -> increases capillary permeability) Decreased surfactant can cause atelectasis |
| Major Burn Effects on Cardiovascular Status 2 | Cap permeability causes fluid to leak & seep between cells which forces intracellular intravascular fluid out of vesicles & (3rd spacing) which causes edema. HR will increase. Will have hyperkalemia, > hematocrit, low sodium. No diffusion in lungs |
| Major Burn Effects on Cardiovascular Status Interventions | Maintain fluid volume manually., As long as edema patient’s body is leaking fluid due to inflammatory response. Body can reabsorb the fluid 4 hrs to 48 hrs after injury. Suction if needed |
| Major Burn Effects on Thermoregulation | high risk for hypothermia due to loss of integumentary system parts. Keep warm, may need a device. |
| Major Burn Effects on Metabolism | increases because body takes more energy to try to heal. Insulin resistance due to damage to cells and less organ perfusion. Compensatory at first, but they become counterproductive quickly Edema: injured tissue & noninjured as well (systemic) |
| Nursing Priorities of Burns by Phase: Emergent/Resuscitative | (onset of injury to completion of fluid resuscitation) ER -> Fluid resus. ->Foley catheter inserted If burns >20-25% will need NG tube & suction enabled |
| Nursing Priorities of Burns by Phase: Emergent/Resuscitative 2 | Pt stabilized & continually monitored Remove clothing & jewelry Remove contacts for chemical burns prevent burning eyes Clean sheets under & over to prevent infection Baseline height & weight, including prior to injury so tracking is possible. |
| Nursing Priorities of Burns by Phase: Emergent/Resuscitative Labs | electrolyes, hct, abg’s, drug panel, alcohol panel, UA |
| Nursing Priorities of Burns by Phase: Emergent/Resuscitative Vaccines & Vitals | Tetanus shot – esp if patient came in dirty Get BP – if burn in BP area: clean dressing & take BP anyway. If can’t hear use Doppler Frequent vitals For electrical burns, get ECG Address pain – only use IV meds (likely 2 IVs & maybe a central line) |
| Nursing Priorities of Burns by Phase: Emergent/Resuscitative Psychosocial & Emotional Support | for pt & family (keep them calm, keep talking to them) |
| Nursing Priorities of Burns by Phase: Emergent/Resuscitative Complications | Same as shock plus Acute respiratory failure Distributive shock Acute kidney injury Compartment syndrome (d/t eschar – totally burned) symptoms Paralytic ileus Curling ulcer (ulcer forms) |
| Nursing Priorities of Burns by Phase: Acute/Intermediate | from beginning of diuresis to wound closure appear 48-72 hrs later Dress wounds – sterile technique |
| Nursing Priorities of Burns by Phase: Acute/Intermediate Family | clean water rinsing to clean patient. Encourage family to participate. Good time for education. Give coping strategies Support family and/or spouse Help them understand the pt’s reactions |
| Nursing Priorities of Burns by Phase: Acute/Intermediate Diet | high calorie nutrition – pt will lose weight d/t using fat for energy |
| Nursing Priorities of Burns by Phase: Acute/Intermediate Complications | fluid & electrolyte imbalances urinary output shifts sepsis respiratory failure visceral damage (electrical burns) |
| Nursing Priorities of Burns by Phase: Rehabilitation | (prolonged & long term. From wound closure to return to optimal physical & psychosocial adjustment) Pain management: one of most painful types of acute pain |
| Nursing Priorities of Burns by Phase: Rehabilitation Treatment | wound cleaning, dressing changes give meds frequently & at larger doses (metabolize faster than normal people) Morphine, fentanyl, or whatever (IV) work thru anxiety regarding therapy pain |
| Nursing Priorities of Burns by Phase: Rehabilitation Pain Types | background/resting, procedural, breakthrough |
| Nursing Priorities of Burns by Phase: Rehabilitation Complications | Sleep deprivation because can’t get into comfortable position Anxiety |
| Nursing Priorities of Burns by Phase: Rehabilitation Interventions | wound healing, psychosocial support, self-image, lifestyle, restoring maximal functional abilities so that the pt can have the best quality of life personally & socially Rehab starts as early as possible after the emergent phase & extends for a long time |
| Nursing Priorities of Burns by Phase: Rehabilitation Resources | may need reconstructive surgery to improve function & appearance Vocational counseling & support groups |
| Debridement Types | Surgical Mechanical Natural |
| Debridement Types: Surgical | with sharp object – shaving burned skin layers |
| Debridement Types: Mechanical | topical & enzymatic debriding agents. Put on skin & then put dressing on |
| Debridement Types: Natural | body separates dead tissue from viable tissue all by itself (goal of enzymatic agents), but may need surgery option also |
| Burn Healing: Nutrition | metabolic abnormalities. enteral food at night & PO during day Goal: nitrogen balance & nutrient utilization diet based on preburn status & TBSA % Jejunal feedings=nutritional status w/ lower risk of aspiration pt w/ poor appetite/weakness |
| Reason for Compression Devices | Reduce edema, help keep fluid from seeping into interstitial space – keeping in intravascular space as it should be |
| Compression Therapy Education | Wear 24 hrs a day, only taking off to shower |
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