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Fundamentals - Henderson VNE Rusk

What is the fifth vital sign? Pain
What difficulties does having pain cause? Perform ADL's, Rest and experience restorative sleep, Eat, movements and exercise, relationships, work or maintain job, social life, cognitive abilities, focus on spiritual beliefs.
What other type of drug can help with pain for some patients? antidepressants
Falling asleep does not mean the patient does NOT have pain.
Gate control theory transmission of pain impulses to the CNS are controlled by a "gate". Gate is open for pain to be transmitted to the brain and closed when the nerve impulse for pain is blocked from transmission.
When is the gate closed in the Gate control theory? nerve impulse for pain is blocked from transmission. Stimulation of Broad nerve fibers close the gate.
What are stimulating factors? Exercise, heat, cold, massage, TENS unit.
Acute Pain comes on shortly, in SHORT duration. Less than 6 months.
Chronic Pain lasting more than 6 months.
Intermittent pain Comes and goes in intervals
Intractable pain pain that can not be relieved.
Referred Pain Pain felt in an area other than where the pain was produced.
Radiating Pain Begins at a specific site and shoots out to a larger area beyond the site of region.
Nociceptive pain occurs from stimulation of nerve pain receptors, generally localized.
What stimulates pain receptors? Temperature changes, tissue damage, certain chemicals.
What are types of nociceptive pain? cutaneous, visceral, deep somatic pain
Cutaneous pain skin surface and underlying subcutaneous tissue. EX Paper cut or mild burn.
Visceral pain soft tissue pain caused by stimulation of deep internal pain receptors. ex. trauma, surgery, cancers of skin, muscle and organs. Sometimes called cramping.
Deep Somatic Pain osteogenic pain, bone, ligament, tendon, blood vessel pain.
Neuropathic Pain Occurs due to injury or destruction of peripheral nerves or CNS. - Extends beyond local region.
How is neuropathic pain described? burning, stabbing, deep ache, sharp, jagged, knife like pain or numbness. EX Phantom limb pain, diabetic neuropathy
Developmental stage factors pain reactions. Crying, changes in facial expressions, increased pulse and respirations
Factors affecting pain Personal support system, Emotions, Fatigue, Body responds to pain
Physiological signs of Acute Pain Recent onset, diminishes with healing, increased heart rate, increased respiration, increased in systolic blood pressure (1st); pupils dilate.
Worsening signs of acute pain diaphoresis, blood pressure drops, syncope, pupils constrict
Behavioral signs of Acute Pain Wincing or facial grimacing, moaning, crying, restlessness, nervous finger tapping, foot bouncing, rigid body movements, slow movement, holding or guarding the area, worsens during anxiety or fear, rocking or pacing.
Psychological Signs of Acute Pain Reduced Attention span, focused on pain only, Anger, Fear, Anxiety, Irritability
Physiological Signs of Chronic Pain Onset atleast 6 months ago, pupils may constrict, VS may not change.
Behavioral signs of chronic pain lassitude (fatigue); impaired mobility, sleep disturbance, withdrawal from family and friends.
Psychological Signs of chronic pain low self esteem, depression, fatigue, anger, irritability
Characteristics of pain sharp, dull, intermittent, constant, burning, cramping, stinging, aching
Pain Assessment When did it start? What causes the pain? (eating, inspiration, expiration) What does the patient want to do about the pain? (medications or nonpharmalogical methods)
What are relief measures of pain? hot and cold packs are good for musculoskeletal pain. Massage, TENS, Acupressure and acupuncture, Meditation or progressive relaxation
TENS transcutaneous electrical nerve stimulator
What does a TENS do? sends electrical pulses to large diameter nerves and may stimulate endorphins.
What is the systematic process of progressive relaxation or meditation? using the mind to relax the muscles from the top of the head to the toes.
Nonpharmaceutical pain Relief Measures Distraction - Read a book, watch a movie, listen to music, chanting, sounds of nature, sermon, receive a back rub, foot fub, head massage, hair brushing, have a conversation, study! hmmm.... play game
What is the best option of pain medication for severe pain? opiates Narcotics
What are Opiate Narcotics? They are analgesics that relieve visceral and deep somatic pain, they are considered scheduled medications, administed po, rectal, transcutaneous, IM, IV.
Adjuvant Drugs produce pain relief from another method or increase effects of opiates, opiods, and nonopiod drugs. Andtidepressants and anticonvulsants are combined to treat nuropathic pain in diabetes.
Restorative sleep allows individuals to awaken feeling rested, refreshed and energized. Partial loss of consciousness, more difficult to arouse, sounds incorporated into dreams.
Rest may or may not involve sleep. external noises awaken person, fells relaxed and free from stress.
What do you need to maintain good health? rest or restorative sleep
Why is restorative sleep important? It is when the brain works to repair the body, mind, and emotions. Brain uses sleep time to sort out all the data.
What kind of problems occur if you do not get adequate sleep? Healing is slow and incomplete, immunity and pain tolerance decrease, fragile emotions and impatience affect relationships, cognitive functions are impaired, work performance suffers, accidents increase.
Circadian Rhythm 24 hour cyclical pattern where the bodies metabolism and functions increase and decrease in rhythmic patterns.
When is body temp at its lowest? Body temp is lower in the early morning.
What is sleep? cycles and alternates with longer periods of wakefulness.
What are the cycles of sleep? Non Rapid Eye Movement Sleep NREM and Rapid eye movement sleep REM
What is stage 1 of NREM sleep Relaxation begins, metabolism and VS begin to slow, lightest sleep occurs only a few minutes, easily aroused and feel like you were daydreaming when awakened.
What is stage 2 of NREM sleep? Relaxation deepens as metabolism continues to get slower, start of sound sleep but still easily aroused, lasts 10- 20 minutes.
What is stage 3 of NREM sleep? Last 15-30 minutes, deep sleep begins, muscles are completely relaxed, VS slow down further and body becomes immobile, arousal is more difficult.
What is stage 4 of NREM sleep? Difficult to arouse, deepest sleep last 15-30 minutes, more time is spent here is you are sleep deprived, body is rested and restored, eyes are still but dreaming can occur here.
What is REM sleep occurs at the end of each NREM cycle. 1st cycle happens about 90 minutes after sleep begins, REM begins and VS fluctuate, Brain is very active and engaged in vivid dreaming, duration increases with each cycle averaging 20 minutes.
Newborn sleep requirement 16-18 hours a day
Infants up to 2 years sleep requirement 12-14 hours a day
3 years to 6 years sleep requirement 12 hours a day
Children 7 to 12 sleep requirement 10 hours per night
Adolescents sleep requirement 8.5 to 9.5 hours per night
Young adults sleep requirements 7.5 to 8 hours a night
Older adults sleep requirements 5.5 to 6 hours a night
What are factors that affect sleep? smoking, drinking, night shift, stress and anxiety, too hot or cold, noises, bright lights, uncomfortable bed, illness and health problems, pain, discomfort, sob, dyspnea, itching, GERD, Sinus drainage, congestion, coughing, fever, diaphoresis, nocturia
What promotes better or normal pattern of sleep? Exercise early in the day or performed 1 to 2 hours before bedtime.
Bruxism grinding of teeth while sleeping
insomnia chronic inability to fall asleep or stay asleep
Narcolepsy uncontrollable recurrent daytime episodes of sleepiness. can hinder driving and operating dangerous equipment.
Night terrors nightmares in children, causes awakening and fear.
Sleep Apnea inability to maintain breathing while sleeping, usually snores, quits breathing for about 10 seconds to 2 minutes, can be life threatening.
somnambulism sleep walking
sundowning confusion or disorientation in elders that happens in the evening hours.
Interventions to promote sleep prepare the environment (room temp, blankets, pillows, clear path to door from bed, dim lighting, reduce noise with closed door)
Promote sleep by preparing for comfort and relaxation brush hair, teeth, and wash face. offer snack, assist with toileting, pain assessment, play soft music, provide ROM exercises, allow patient to express feelings or concerns. sleep medications if prescribed.
What is nociceptors nerve pain receptors
What are the Four basic categories of medications for pain relief? NSAIDS, Nonopioids, Opioid Narcotics, Adjuvant Drugs
What do NSAIDS do? Reduce inflammation, ibuprofen, aspirin, naproxen
Nonopioiods Nonnarcotic pain relivers - Tylenol
Opioid Narcotics alalgesics, relieve visceral and deep somatic pain, best option for severe pain relief. controlled substance, restrictions, lockout method
How often do you asses pain? q 2 hours.
What is the airway? path that air takes as it enters and exits the lungs.
Normal pathway nostrils to the pharynx to the trachea to the R and L Bronchus to bronchioles and the alveoli
What do you want airway to be? patent, no blockage
What is the diaphragm? mechanism for Inhalation. contracts in response to stimulus from phrenic nerves and moves downward.
What is exhalation air is force out of the lungs
Where does external Respiration take place? between alveoli and the capillaries
How does oxygen move? diffusion
What are the effects of chronic lung disease on respirations? air is trapped in the alveoli, raises blood level of carbon dioxide and lowers oxygen level which causes the resp rate to increase.
What moves carbon dioxide out of the body? Increase levels of carbon dioxide, decrease oxygen to move the carbon dioxide.
What is the maximum L for COPD patients? 2-3 L/min Maximum!
Hypoxemia oxygen levels in the blood drop below normal range.
Hypoxia blood cannot make adequate amounts of oxygen to the tissues
What is the earliest sign of hypoxia confusion
Signs of hypoxia confusion, disorientation, ha, irritability, restlessness, tachypnea.
What is tachypnea a sign of hypoxia usually because of the increase in CO2 levels, this is the way the body is trying to get rid of excess of CO2. Blowing it off!
If you walk in a room and see struggling what would you do? help the patient slow down their breathing and ask them to breathe in and out at the tempo you want them to breathe.
Would you leave a patient that is anxiety about breathing? Never
What do you if you see cyanosis? late sign of hypoxia, take immediate action and notify MD.
Exertional dyspnea difficulty breathing while ambulating a brief distance.
orthopneic position sitting upright and leaning slightly forward with arms and head over a table. allows for a bigger chest expansion allowing them to inhale more air.
Life threatening color of sputum pink frothy or bubbly, fluid and blood mixed together, seen in pulmonary edema.
hemoptysis blood in sputum, rust colored, seen in TB or pnumonia.
Palpation hands on either side of chest, determine if each side of chest is moving equally as pt inhales and exhales (excursion)
What can the difference in the chest wall movement indicate? Airway obstruction, pneumothorax, pleural effusion
pleural effusion fluid in the chest cavity pleural linings.
crepitus air in the subcutaneous tissue, chestwall, face, and neck. sounds like rice crispy crackling. Notify MD, looks like bubble wrap.
normal o2 sat healthy person 95-100%
normal o2 sat for copd patient 89-92%
Sputum Culture patient coughs to bring up sputum in a STERILE container, may suction throat and trachea for specimen, usually done in early morning prior to breakfast
ABG (arterial blood gas) determines respiratory or metabolic acidosis or alkolosis. keep on ice during transport to lab.
Blood gas components ph, PaO2, PaCO2, HCO3, SaO2
Ph normal 7.35-7.45, Significance if above normal is alkalosis and below normal is acidosis.
PaO2 normal 75-100 mm HG; above normal means hyperventilation, and below hypoxemia
High PaO2 indicates hypoxemia
PaCO2 normal 35-45 mm Hg; above normal converts to carbonic acid and causes acidosis. below normal lack of carbonic acid and causes alkalosis.
HCO3 normal 22-26; above normal excess of alkinity causes alkalosis and below normal lack of alkininity leads to acidosis.
SaO2 normal 95% - 100%, above normal - hyperventilation or excess supplemental oxygen and below normal means hypoxemia or hypoxia
Nursing intervention for impaired oxygen turn,cough, deep breath every 2 hours. incentive spirometry, nebulizer, conserve energy, oxygen
Incentive Spirometry device with one or more chambers and mouth piece, goal is to imporve volume of inhalations, helps expand the lungs fully and prevent atelectasis, repeat every hour and atleast 10 minutes at a time.
nebulizer used to administer liquid bronchodilator or saline through a machine with air compressor via mask or hand held mouthpiece.
Safety for use of O2 no smoking. no open flame, check electrical devices for frayed wires, avoid static electricity, no petroleum based products.
What can too much oxygen lead to? CNS damage, oxygen toxicity
S/S of Oxygen toxicity substernal chest pain, dry cough, n/v, HA, sore throat
Why would you not put 2L on simple face mask? Flow rates less that 5L/min will cause CO2 to accumulate in the mask.
Nasal Cannula Liter Flow 1-6L/min, o2 to snares. can easily talk and eat, pt must breath though nostril for full benefit. Prongs curve inward, tubing slipped over ears.
Simple face mask Liter flow 5-10L/min; O2 directly to mouth and nose, flow rates less than 5L/min cause Co2 to accumulate in the mask.
Partial Rebreathing mask Liter - 6-15L/min; mask with bag attached that traps the Co2 for rebreathing ph levels, ports on the side of the mask allow exhaled air to discharge. Bag WILL NOT collapse when used properly.
Non Rebreathing mask levels 6-15L/min; prevents rebreathing exhaled air, escapes through one way valve, bag traps o2 as a reservoir for inhalation, THIS IS THE ONLY DEVICE THAT CAN PROVIDE 100% O2 WHEN SET AT 15L/MIN
Venturi Mask liter flow 24-80%, plastic valve, allows precise mix of air and oxygen. gives more exact control especially for COPD patients.
Face tent liters - 8-12L/min; Allows for high amounts of humidity to be used d/t open top. o2 is not delivered precisely so must assess.
Tracheostomy collar 4-10 L/min; rests over tracheostomy with elastic band around the neck.
T Piece 4-10 L/min; attaches to the flange of the tracheostomy. o2 flows from one side of the T.
Airway Assistance artificial airway used to assist in maintaining a patent airway, made of hard plastic or rubber,
Where can the endotracheal be inserted? mouth or nose
Why is oropharyngeal airway slightly curved? to hold the tongue in place so that it doesnt obstruct the airway of an unconscious person.
What catheter do you use if you going into the nose, trachea, or lungs soft rubber catheter
What catheter do you use if you are going into oral cavity? yankeur suction, made of hard plastic
Obturator fits inside the outer cannula and forms a smooth end for inserting the tracheostomy tube, removed once tube is in place, keep in room in case trachea comes out and needs to be reinserted.
What is the difference in the tubes on a patient that has pneumohemothorax the higher tube is for air and the bottom one is for blood. They are joined by a Y connector and then connected to the drainage system.
Do not let the chamber get below? -20 cm line. bubbles should be present with suction unless dry suction.
What is chamber one? left chamber, used for wet suction
What is chamber two? middle chamber, water seal chamber.IF you see bubbling in this chamber check for air leak.
What is chamber three? collection chamber - beginning of shift is 500ml, 8 hours later there is 600ml, how many mls for your shift. 100 mls.
Notify the prescriber if the output of chest tube becomes bright red or suddenly increases.
Mucuous Membrane alarm pink, ashy fluffy membrane
Why would you treat strep quickly? strep can get worse quickly, treat asap.
Why would you not put a artificial airway in a patient? if they are conscious
Most precise concentration venturi mask
what is best choice of O2 to begin with nasal cannula
Accessory muscles used when difficulty in breathing, neck, shoulders, chest.
no oral airway
Created by: Crystalflow