N12 Midterm 1
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Differentiate the roles of the interdisciplinary team
Nurse- promote health and wellness, diagnose human response to injury/illness
Doctor- Diagnoses illness/injury
Describe the role of the nurse in holistic assessment using ESCAPE-C
Nurses are supposed to diagnose the human response to injury/illness and prevention thereof. Individualize and prioritize pt care
what does ESCAPE-C stand for?
- Physical Exam,
- Education - Collaboration
ID the sources and types of assessment data nurses gather
Physiological data, psychological data, sociocultural, spiritual, economic and life-style factors as well.
actual vs potential/high risk patient problems
Potential/High Risk are things that could go wrong with the patient or have a chance of going wrong.
Actual problems are problems that the pt is currently suffering from.
How do you write an expected outcome?
- Indicate a desired state. They contain action word/verb and a qualifier that indicate the level of performance that needs to be achieved.
- Ambulates safely with one-person assistance. Identifies actual & risk environmental hazards.
- Demonstrates signs of sufficient rest before Surgery
How do you set up a deadline to achieve expected outcomes?
- T= time-framed
What is the purpose of charting outcomes?
To appraise the extent to which goals and outcome criteria of nursing care have been achieved.
What is the significance of assessing pt's use of CAM therapies?
It is important because there is a high risk of complication if combining therapies without adequate communication
Describe levels of evidence based practice
- Active Testing,
- Concrete Experience,
- Reflective Observation
Why do we set up outcome goals?
We want to start with the end in mind. If you do not set an outcome goal you can get off course
Purpose of Nursing Process:
- To identify a client’s health status; his Actual/Present and potential/possible health problems or needs.
- To establish a plan of care to meet identified needs.
- To provide nursing interventions to meet those needs.
- To provide an individualized, holistic, effective and efficient nursing care.
Steps of the Nursing Process
- A – Assessment (what data is collected?)
- D – Diagnosis (what is the problem?)
- O - Outcome Identification - (Was originally a part of the Planning phase, but has recently been added as a new step in the complete process).
- P –Planning (how to manage the problem)
- I - Implementation (putting plan into action)
- E - Evaluation (did the plan work?)
Four Types of Assessment:
- Initial assessment – assessment performed within a specified time on admission Ex: nursing admission assessment
- Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment. Ex: problem on urination-assess on fluid intake & urine output hourly.
- Emergency assessment or rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest.
- Time-lapsed assessment- reassessment of client’s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained.
Types of Data:
Subjective data also referred to as Symptom/Covert data
- information from the client’s point of view or are described by the person experiencing it.
- information supplied by family members, significant others, other health professionals are considered subjective data.
- Example: pain, dizziness, ringing of ears/Tinnitus
Objective data also referred to as Sign/Overt data
those that can be detected, observed or measured/tested using accepted standard or norm.
Gordon’s Functional Health Patterns:
- Health perception-health management pattern.
- Nutritional-metabolic pattern
- Elimination pattern
- Activity-exercise pattern
- Sleep-rest pattern
- Cognitive-perceptual pattern
- Self-perception-concept pattern
- Role-relationship pattern
- Sexuality-reproductive pattern
- Coping-stress tolerance pattern
- Value-belief pattern
Nursing Diagnosis is a statement that describes a specific human response to an actual or potential health problem that requires nursing intervention written in P E format
- P = Problem: use North American Nursing Diagnosis Association (NANDA) category
- [due to or related to]
- E = Etiology: cause of the problem
Guideline for setting priorities:
- -Life-threatening situations should be given highest priority.
- -Use the principle of ABC’s (airway, breathing, circulation)
- -Use Maslow’s hierarchy of needs.
- -Consider something that is very important to the client.
- -Actual problems take precedence over potential concerns.
- -Clients with unstable condition should be given priority over those with stable conditions. Ex: attend to client with fever before attending to client who is scheduled for physical therapy in the afternoon.
- -Consider the amount of time, materials, equipment required to care for clients. Ex: attend to client who requires dressing change for postop wound before attending to client who requires health teachings & is ready to be discharged late in the afternoon.
- -Attend to client before equipment. Ex: assess the client before checking IV fluids, urinary catheter, drainage tube.
- -Plan nursing interventions/nursing orders to direct activities to be carried out in the implementation phase.
What are different forms of nursing in
Independent Nsg. Intervention – those activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills.
- Dependent Nsg. Intervention – those activities carried out on the order of a physician, under a physician’s supervision, or according to specific routines.
- Interdependent/Collaborative – those activities the nurse carries out in collaboration or in relation with other members of the health care team.
Normal level of PaO2
Normal level of PaCO2
Normal level of pH
- Female 11.7-16.0 g/dL
- Male 13.2-17.3 g/dL
- Female 35-47%
- Male 39-50%
Normal Inspiratory Capacity,
- PO2 80-100
- P02 Sat 90-100
- pH 7.35-7.45
- PCO2 35-45
- HCO3 22-28
The first order neurons:
Second order neurons:
Third order neurons:
First : transmit from sensory receptor to the dorsal horn neurons
Second: transmit to the thalamus
Third: transmit to the sensory cortex
Nociceptors are free nerve endings that respond the above stimuli. They are found under the epidermis, within joint and bone surfaces, the deep tissues, muscles tendons and subcutaneous tissues. They are not evenly distributed in the the body, so the relative sensitivity to pain differs according to the area of the body.
Chemical mediators in pain response include :
bradykinins, histamines, prostaglandins
Chemical Initiation of Pain
chemicals released from injured and traumatized tissue make the nociceptor more permeable by damaging its membrane. Results in depolarization of the nociceptors membrane
decreased blood flow to tissues results in an accumulation of metabolic byproducts (lactic acid) which results in stimulation of nociceptors
This can happen with edema which decreases blood flow to areas.
Stimulation of mechanosensitive nociceptors
compression of blood vessels by the spastic muscle – this leads to decreased blood flow – increased concentration of lactic acid. The situation is compounded by an increase in tissue metabolism in the spastic muscle.
What are two types of nociceptors
A fibers: fast fibers, myelinated, carry acute, sharp, sudden pain messages
- Lightly myelinated fibers
- Well localized, sharp pain
C fibers: slow fibers carry diffuse, throbbing pain
- Small unmyelinated fibers
- Diffuse burning, aching
- Because the C fibers are non myelinated, the transmission is relatively slow and poorly localized.
- The A fibers transmit much more quickly
- Proposed by Patrick Wall and Ronald Melzack in 1965
- The theory states that pain is a function of the balance between the information traveling into the spinal cord through large nerve fibers and information traveling to the spinal cord through small nerve fibers
- Remember large nerve fibers carry non-nociceptive information and small nerve fibers carry nociceptive information
- So if the relative amount of activity is greater in large nerve fibers, there should be little or no pain. However, of there is more activity in small nerve fibers, then there will be pain.
- According to the gate control theory, the neurons involved in gating mechanism are activated by large diameter (faster –propagating fibers) that carry tactile information.
- The simultaneous firing of the large diameter touch fibers has the potential for blocking the transmission of impulses from the small diameter myelinated and unmyelinated pain fibers.
What are the Nursing Responsibilities r/t pain?
- Listening to concerns
- Assessing pain intensity
- -Distress levels 0 – 10 pain scale
- Planning for care
- Educating client about pain
- Promoting use of non pharm techniques
- Evaluating process
How do you assess for pain?
- Onset and duration
- Location / distribution
- Aggravating/relieving factors
- Associated features or secondary signs/symptoms
- Associated factors: stress/ fatigue/ activities/nausea
- Treatment response
Tolerance vs. Threshold of pain
- Tolerance: the amount of pain a person is willing to endure.
- Threshold: the lowest intensity of a painful stimulus that is perceived by a person as pain
A factor which increases pain tolerance is:
- Short duration
- Sharp, stabbing, shooting
- Indicates injury
- Physical responses:
- -Change in BP
- -focusing on pain
- Defined in vague terms
- Cause maybe unknown
- Chronic non-malignant pain. i.e. back pain
- Chronic malignant pain. i.e. cancer pain
- Not readily treatable
- Associated with despair and withdrawal, poor sleep, decreased concentration
Sources of Pain
-Superficial – cutaneous
-Somatic- tissues of body wall, muscle, bond, cartilage, tendons, joints, nerves
- -Visceral – organs and their capsules
- Referred pain: felt in an area distant from site of stimulus
- -Neuropathic: damage or injury to nerve
-Inflammatory pain is the most common pathologic condition causing pain.
-Neuropathic pain causes numbness, burning, stabbing, needles.
-Any of these sources of pain can produce acute or chronic pain.
Interventions for pain
Administration of pain relieving medication
Repositioning the client
Heat and/or cold
Facilitating the client’s expression of feelings
Providing support and reassurance
Reducing external stimuli
Teaching the client self – management strategies
Providing diversion therapy
Non Pharm Management of pain
- Heat or cold packs
- Relaxation therapy
- Art or music therapy
- Diversion techniques
- Chiropractic manipulation
- Therapeutic touch
TENS = Transcutaneous electrical nerve stimulation
Non opioid analgesic
Opioid Narcotic Analgesics
Morphine and Codeine are the only naturally occurring opiates. Narcotic is the general term used to describe morphine like drugs that produce analgesia and CNS depression.
Action of Narcotic Meds
- Decreased GI motility (constipation)
- Euphoria (addiction, physical dependence)
- Miosis (pinpoint pupils)
- Physical dependence
- Respiratory depression
Every patient that is given a narcotic medication is a fall risk, be sure to put the rails up and advise the patient not to get oob without assistance.
Adverse Effects of Opioid Analgesics
- Nausea and Vomiting
- Sedation / Respiratory depression
- Circulatory depression
- Cutaneous effects
- Urinary retention
Constipation due opiods
Constipation is the most common side effect seen with opioid use and results from the increased smooth muscle tone and decreased motility of the GI tract
Respitory depression due to opiods
is caused by diminished sensitivity of the respiratory center to carbon dioxide. All opioids have the potential to produce respiratory depression, which can be rapidly reversed with an opioid antagonist, typically naloxone. Carefully assess and reassess each client after giving the medication for the occurrence of respiratory depression. Also remember that if you have to give Narcan, the respiratory depression of opiods will outlast the narcan, so you may have to repeat the dose.
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