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181 Cards in this Set
- Front
- Back
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Examples of classifying pain by origin
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superficial, visceral, somatic, radiating/referred, phantom, psychogenic
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Touched hot object, paper cut
Short term classification of pain |
superficial
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Pain originated from internal organs
Abdominal cavity, cranial, thorax Menstrual cramps, labor pain, gastrointestinal infections, bowel disorder, organ cancers |
visceral
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Diffuse pain
Sprain, arthritis, bone cancer |
somatic
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Starts at origin but extends to other locations
Sore throat, radiates to ear and head Occurs in one area, but pain is at another site Heart attack seen in left arm, back, and jaw |
referring/radiating
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Pain received from an area that has been surgically removed
Patient with amputated limb may still perceive the leg as existing, so may feel pain, itching etc |
phantom
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Pain received from the mind
Pain is not actually there |
psychogenic
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Pain by cause
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nociceptive
neuropathic |
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most common pain received
Pain receptors respond to stimuli that are potentially damaging Noxious thermal, chemical, or mechanical Trauma, surgery, inflammation |
nociceptive
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Complex and often chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signal even in the absence of painful stimuli
Described as “pins and needles Nerve injury by uncontrolled diabetes, a stroke, tumors, alcoholism, amputation, or a viral infection (shingles, HIV/AIDS) |
neuropathic
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Pt describes pain
Sharp or dull, aching, throbbing, burning |
the quality
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pain by duration
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acute, chronic, intractable
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Short duration, generally rapid onset
May last up to 6 months Most associated with injury or surgery Will generally disappear as the injury heals |
acute
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Lasts 6 months or longer and interferes with ADL’s
Related to a progressive disorder or can occur when there is no current tissue injury (neuropathic pain) May lead to depression, withdrawals, anger frustration and dependence. Feared when contracting cancer or other progressive disease |
chronic
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Both chronic and highly resistant to relief
Frustrating for the patient and care provider Approached with multiple methods of pain relief |
duration
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5. It is most important for the nurse to understand the various ways in which pain is classified
a. so that he can document the client’s pain using accurate terms b. so that he can be clear in his communication with the physician c. so that he can develop an effective pain management plan d. so that he can educate the client thoroughly |
c- you must relieve pain
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Pain impulses can also be modulated at the spinal level
Pain is perceived by two types of fibers, those that produce pain and those that inhibit pain- does not occur by direct stimulation of nociceptors As pain travels from periphery to brain, they encounter a “gate” that allows or blocks the transmission of pain sensation in the brain. |
The gate-control theory
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gate control theory
__= gate closed __= gate open |
non pain
pain |
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Example
1. Hit your arm- reach down to message area. This closes some of the gates 2. Sitz bath after childbirth. This warm water and gentle pressure blocks gate to the perception of pain in the brain. |
gate- control theory
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can be physical, emotional, behavioral
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gate theory
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Transduction, transmission, perception and modulation
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physical
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Descending impulse from brain- Open or close the gate
Medications for depression are used for pt with chronic pain |
emotional
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Visual analogue scale
numeric rating scale simple descriptor scale wong-baker faces pain |
pain scales
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nurse is assessing the confused client. In trying to determine the client’s level of pain, the nurse should
a. be aware that confused clients don’t feel as much pain due to their confusion b. observe the client carefully for changes in behavior or vital signs c. ask the client’s family how much pain the client normally has d. use only pain scales that feature numbers or “faces” the client can point to |
B
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May provide some relief
Particularly helpful in arthritis points Remember to strengthen area by excersice Pt may naturally do this by limiting use |
immobilization and rest
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cognitive-behavioral interventions
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distractions
progressive muscle relaxation guided imagery hypnosis therapeutic touch humor journaling back message |
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Drawing pt’s attention away from pain towards something else
Based on the belief that your brain can process only so much information at a time Most affective in mild/moderate term, but used in severe pain |
distraction
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Visual- Football game on TV
Tactile -Message- Intellectual- crossword puzzle Auditory- music |
types of distractions
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Also called sequential muscle relaxation
Reduce pain, especially if chronic |
progressive muscle relaxation
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Technique
Pt sits comfortable and tenses a group of muscles for 15 seconds and then relaxes the muscles while breathing out Brief rest Repeat Usually start with facial muscles and work down to feet |
technique for progressive muscle relaxation
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Uses auditory and imaginary processes to affect emotions and help calm and relax
Most affective in chronic pain Pt uses imagination to create images of temporary escape that will elicit sense of well-being |
guided imagery
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Induction of a deeply relaxed state
Hypnotist offers therapeutic suggestion Ex: pain will be turned down like volume on radio |
hypnosis
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Does not require physical contact
Focuses on the use of the hands to direct energy fields surrounding the body |
therapeutic touch
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Positive affects on a patients physical and emotional health
Indicates mental well-being and boosts immune system Helpful when used before a procedure |
humor
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Expressive writing can help reduce chronic pain
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journaling
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For severe pain
Better for visceral, rather than neurological |
opioid analgesic
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Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse?
a. "If you take more morphine, it will not change your pain relief." b. "I'll call the physician and ask for an increased dose." c. "The amount you are taking now is all I can give you." d. "I'm worried if we increase your dose that you will stop breathing.” |
B bc its difficult to meet the gate of pain
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factors affecting sleep
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age, lifestyle factors, an illness, environmental factors
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affects duration and sleep pattens (REM)
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age
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types of lifestyle factors
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physical activity, food and alcohol, medications, caffeine and nicotine, sleep habits
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If exercise occurs at least 2 hours before bedtime it promotes sleep
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physical activity
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__can promote or interfere with sleep
Carbs/fat make you tired Hunger makes you not sleep (infants/children) |
diet
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Makes you fall asleep, but interrupts REM
Can interrupt sleep bc it’s a diuretic (nocturia) |
alcohol
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May induce sleepiness, grogginess, sedation
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medications
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___- difficulty falling asleep
___- varies, may induce insomnia |
nicotine
caffeine |
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increases need for sleep/rest
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illness
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Temperature and humidity
Noise and light Nonoxious odor Comfort of bedding |
environmental factors
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The nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, “I don’t know what is wrong with me. I have been napping all day and can’t seem to think clearly.” The nurse’s best response is
a. You are sleep deprived, but that will resolve in a few days.” b. “You are experiencing hypersomnia, so it will be important for you to walk in the hall more often.” c. “There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?” d. “I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep.” |
C
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common sleep disorders
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sleep apnea and snoring
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Periodic breathing cessation for at least 10 seconds during sleep
Linked to heart disease May feel fatigued the next day Long term detrimental |
sleep apnea
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types of sleep apnea
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obstructive sleep apnea
central sleep apnea |
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usually due to obesity
caused by airway occlusion |
obstructive sleep apnea
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dysfunction in respiratory control
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central sleep apnea
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Hallmark of Obstructive sleep apnea. But does not necessarily indicate this
Muscles ay back of mouth relax during sleep, obstruct the airway and vibrate with each breath |
snoring
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For which sleep disorder would the nurse most likely need to include safety measures in the client’s plan of care?
a. snoring b. enuresis c. narcolepsy d. hypersomnia |
C
Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. This could put the person at risk for harm depending on the activity in which he is engaged. |
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Sleep Deprivation *
Disturbed Sleep Pattern r/t worries about family Disturbed Sleep Pattern r/t noise of hospital environment Insomnia Risk for Injury r/t narcolepsy |
nursing diagnosis
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Goal: pt will sleep
Pt amt, consistency, or quality of sleep is decreased over prolonged periods of time. |
sleep deprivation
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__ is a factory that influences pulmonary function
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smoking
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Constricts bronchiole and increased fluid secretion into airways
The longer and the more a pt smokes the more likely he or she is at risk for cancer and chronic lung disease However, once a person stops smoking , the body begins to repair the damage. |
smoking
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Never to late to stop smoking to save some pulmonary function*- both short and long term smokers can benefit.
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smoking
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hypoxia
hypoxemia hypercapnea hypocapnea bradypnea apnea |
problems with gas exchange
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Poor oxygen to tissues and organs (dec oxygen)
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hypoxia
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sensitive early indicator of hypoxia
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altered mental status ->anxiety, agitation, confusion. Restlessness and agitation
due to lack of cerebral perfusion of oxygen |
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Low arterial blood oxygen levels
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hypoxemia
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Excess of dissolved CO2 in the blood
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hyperacarbia
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Low level of dissolved CO2 in the blood
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hypocarbia
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decrease in respiratory rate
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bradypnea
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cessation of respiration (stops breathing)
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apnea
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Which diagnostic test/exam would best measure a client’s level of hypoxemia?
a. chest x-ray b. pulse oximeter reading c. ABG d. peak expiratory flow rate |
c- ABG
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assess breathing pattern and respiratory effort in what exam
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physical
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assess normal and altered patterns
Pain alters rate and depth of respiration. Pts may breathe shallowly and at risk for atelectasis. Regularaly ***** pt for pain Once medicated, Regularly reassess breath sounds, and encourage the pt to breath deeply and cough* |
breathing patterns
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Assess, but be careful not to increase his respiratory effort by using closes questions.
Ask whether SOB began suddenly or gradual, severity (now), whether it gets better or worse. Observe and ask for signs of increased respiratory rate |
respiratory effort
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signs of respiratory distress especially seen in children and infants
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nasal flaring, retractions, use of accessory muscles, grunting, body positioning, paroxysmal, conversational dyspnea, stridor, wheezing, diminished/absent breathing sounds
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Visible enlargement of the nostrils with inhalation. Helps reduce resistance to airflow in the nose and keep the nasal passages open to take in more air.
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nasal flaring
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Visible “sinking in” of intercostal, supraclavicular, and subcostal tissue, caused by excessive negative pressures generated in the chest to try to increase the depth of inhalation.
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retractions
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During respiration, pt may use intercostal, abdominal muscles, and muscles of the neck and shoulders when there is an increased demand for oxygen or problems with ventilation.
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use of accessory muscles
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Caused by involuntary muscles contraction during expiration to help keep aveoli open and enhance gas exchange
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grunting
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To facilitate respirations.- the patient usually finds and upright posture the most comfortable.- allows more room for diaphragm
Orthopnea- difficulty breathing while laying down Ask patient how he or she sleeps. Some patients may report sleep reclined |
body positioning
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Sudden awakening due to SOB that begins during sleep. The patient feels panic and extreme dyspnea and must sit upright to ease breathing
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paraoxymal noctural dyspnea
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Inability to speak complete sentences without stopping to breathe. The more frequently the patient pauses when speaking, the more severe the dyspnea
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conversional dyspnea
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high pitched, harsh, crowning, inspiratory sound caused by partial airway constriction
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stridor
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give epinephrine (can be emergency)
Partial can become complete constriction |
stridor
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Important to look for this in postanesthesia care
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stridor
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Musical sounds produced by partial obstructed small airways. Often heard in pt with asthma and lung congestion.
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wheezing
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Experience dyspnea these are signs of worsening ventilation and oxygenation. Oxygen therapy and measures to restore adequate ventilation may be required.
Ex; Collapse of lungs (pneumothorax) |
diminished/Absent breathing sounds
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11. You are providing care for a post operative patient and hear wheezing in the posterior lung fields. Which would be the appropriate response?
a. Order a stat chest Xray b. Have the patient cough and listen again c. Order an ABG d. Instruct the patient not to breathe so deeply |
B- bc wheezing can be mucus, so we are checking if they can clear mucus
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The term “Kussmaul” refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx.
T OR F |
false, stridor
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promoting respiratory function
mobilizing secretion |
interventions for optimal oxygenation
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Deep regular breathing promotes ventilation and optimizes gas exchange
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promoting respiratory function
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immunization, preventing respiratory infections, support smoking cessation, position (max lung excursion), incentive spirometer, aspiration precautions.
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promoting resp function
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Ex: influenza and pneumonia
Reduces chance of contracting disease |
immunization
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because they may lead to respiratory disease
discourage use of antibiotics because they are overused and cause antimicrobial resistance |
prevent upper respiratory infections
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Ask all pt’s if they smoke
Nurses can provide effective support to patients who want to quite smoking |
support smoking cessation
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An upright or elevated position pulls abdominal organs down, allowing for maximum diaphragm excursion and lung expansion.
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Positioning: maximum lung excursion
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Examples:
Tripod position When patient lying on her side, provide pillows to support arm Assist with frequent changes to keep all areas of the lungs well ventilated, and ambulate as often as possible without creating fatigue. |
Positioning: maximum lung excursion
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a. Promote max lung expansion and increase inspiratory volumes
b. Designed to encourage patients to take deep breaths by reaching a goal-directed volume of air |
Incentive spirometer
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Reserved for pt at risk for atelectasis
Ex: pt who have had abdominal, chest or pelvic surgery or with a history of respiratory problems. |
Incentive spirometer
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Visual clue (elevation of ball/piston) show whether pt is inhaling deeply enough.
And upright position maximizes thoracic excursion. Therefore sitting is the best when using this device |
Incentive spirometer
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Performed:
Hold leveled Maintain a form seal with lips around the mouthpiece during inhalation Inhale slowly Keep the visual indicator at the inspiratory goal for several seconds Remove the mouthpiece and exhale normally |
Incentive spirometer
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A risk for pts with decreased level of consciousness, demished gag or cough reflex or difficulty with swallowing.
Keep suction set up for emergency or routine use |
aspiration precautions
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Deep breathing and coughing
Hydration= Humidified RA/O2 Chest physiotherapy Postural drainage Chest Percussion |
mobilization secretions
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Administers a volume of oxygen designs to supplement the inspired room air to provide airflow equal to the person’s minute ventilation
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low flow device
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Does not meet the pt inspiratory flow rate
If patient is having trouble breathing due to Oxygenation or lung disease give more low, not oxygen amt of flow of O2 going into patient (greater oxygen concentration) have low inspiratory demands Does not increase amt of flow |
low flow device
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types of low flow devices
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nasal cannula (prongs)
simple face mask rebreather mask |
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Have to be able to breath through nose to get through a significant amt of oxygen
Must be awake Assess nares and ears. May be drying. Curved down into nose |
nasal cannula
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Agitated, confused pts generally tolerate this device best
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nasal cannula
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Flow 1-6 L/M,
Fi O2 21-44% Min |
nasal cannula
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Used to deliver oxygen
must be correct size for client. May cause sense of claustrophobia in some. May be uncomfortable. |
simple face mask
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Check skin behind ears and also bridge of nose for sores. also assess cheeks and chin for chaffing and keep skin dry in what low flow device
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simple face mask
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mouth breathers would use this type of low flow device
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simple face mask
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Minimum rate of 5-8 L/min
FIO2 40-60% |
simple face mask
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Must remain slightly inflated at end of inspiration if it does not, increase flow rate
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rebreather mask
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___ mask - 6-11 L/min (60-90% FIO2
___ mask Flow rate is set to keep bag inflated. Flow of 10-15L provides >90% FIO2 |
Partial rebreather mask - 6-11 L/min (60-90% FIO2
Non-rebreather mask Flow rate is set to keep bag inflated. Flow of 10-15L provides >90% FIO2 |
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Used in severe hypoxemia for highest concentration of oxygen delivery
One way valve allow CO2 expelled FiO2 80-95% with flow rate 10L/min Dependent on patient rate and depth of breathing Need snug fit Frequently not well tolerated |
rebreather mask
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Meets or exceeds the patients total inspiratory flow rate
Increased inspiratory demands- Need oxygen at a high pressure to breath in |
high flow device
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Needs help breathing for air in, More flow
Need an humidifier |
high flow device
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Delivers the most accurate O2 content. 24-55% O2 at 4-10 L/min
Mask must fit snugly and tubing must be free from kinks Flow- 4-10 L |
venturi mask
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Flow- 4-10 L
Fi02 25- 50% |
venturi mask
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Amount is dependent on rate and depth patient is breathing
Less claustrophobic than mask |
face tents
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types of high flow devices
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venturi mask, aerosal face mask, tracheostomy collars
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Surgical opening into the trachea through the neck that is temporary or permanent
Inhaled air bypasses the upper airway and goes to lower airways Oxygen maybe delivered this way |
tracheostomy tube
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this may have a low-pressure cuff., a foam cuff, mist collar
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trach tube
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Surgical opening into the trachea through the neck that is temporary or permanent
Inhaled air bypasses the upper airway and goes to lower airways Oxygen maybe delivered this way A tracheostomy tube with a low-pressure cuff., a foam cuff, mist collar |
endotracheal tube
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seals against tracheal wall
prevents gases from leaking past the cuff and allows positive pressure ventilation prevents regurgitated gastric contents going into trachea |
cuff at end of endotracheal tube
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what should your nursing not include when dealing with suction
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Assessment before and after suctioning
Did it work Short note about pertinent vitals, breath sounds, pulse Ox How did patient tolerate breathing |
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In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of
a. Risk for ineffective airway clearance b. Anxiety related to suctioning c. Social isolation related to altered body image d. Impaired tissue integrity |
A bc airway is a vital function
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cardiovascular abnormalities
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Heart failure, cardiomyopathy, cardiac ischemia, coronary artery disease, dysrhythmias, heart valve abnormalities.
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pathophysiology conditions
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cardiovascular abnormalities, peripheral vascular abnormalities, 02 transport abnormalities
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1. Heart becomes an inefficient pump and is unable to meet the body’s demands
2. Blood is oxygenated when it passes through the lungs, but its is not well circulated to the organs and tissues 3. Impaired circulation leads to systemic and pulmonary edema, which further impairs gas exchange |
heart failure
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heart muscle disorder that results in heart enlargement and impaired cardiac contractility
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cardiomyopathy
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Oxygen requirements of the heart are unmet. If prolonged may lead to myocardial infarction as parts necrose from inadequate oxygen
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cardiac ischemia
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includes:
Angina pectoris Transient chest pain due to myocardial ischemia. The tissue becomes injured but does NOT necrose. |
cardiac ischemia
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Leading cause of cardiac ischemia
Plaque builds up inside the arteries |
coronary artery disease
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Lowers CO and decreases tissue oxygenation.
HR or rhythm problems |
dysrhythmias
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1. Creates turbulent flow, leading to decrease in CO and compromised tissue oxygenation
2. Causes Regurgitation and enlarge chambers |
heart valve abnormalities
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Disorder of peripheral blood vessels impair blood flow to and from organs and tissues includes wither venous or arterial abnormalities
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peripheral vascular abnormalities
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Disrupt flow of oxygenation blood to tissues
Signs and symptoms Pallor, pain, weak or absent pulses, poor capillary refill, cool skin, and tissue dysfunction Assess pulse |
arterial abnormalities
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Disrupt blood return to the heart
Assess edema, Venous ulcers, Brown skin, tissue |
venous abnormalities
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Tissues may become hypoxic if blood is unable to carry adequate amts of oxygen
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o2 transport abnormalities
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two types of O2 transport abnormalities
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anemia and CO2 poisoning
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Abnormally low level of red blood cells, hemoglobin or both
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anemia
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a. Colorless, odorless gas produced by the combustion of flammable materials and fuels
b. When inhaled binds to hemoglobin interfering with oxygen carrying sites |
carbon monoxide poisoning
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Ineffective Tissue Perfusion*******
Decreased Cardiac Output******** Activity intolerance Fatigue Risk for Shock*** Acute Pain due to myocardial ischemia Anxiety r/t shortness of breath |
nursing DX for cardiac
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Measures of venous return increase thet flow of blood back to the vena cava and the rt side of the heart
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promoting venous return and prevent clot formation
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Examples:
Elevate the client’s legs above heart and gravity promotes venous return Avoid placing pillows under the knees Use less than 15° knee flexion Encourage leg exercises for a client on bed rest Promote ambulation as soon as possible Encourage or provide frequent position changes Position the client in high Fowler’s position Use Compression devices Fluid restriction if necessary |
promoting venous return and prevent clot formation
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Cardiac or Respiratory Arrest
Heart (pump) or resp system not working enough to sustain life Perform CPR Know if patient has an advance directive!!! Do not resuscitation, no compressions BEFORE YOU GIVE CODE BLUE When giving report |
CODE BLUE
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Immobility promotes venous vasodilation, venous stasis and hypercoagulability of the blood can cause __ and __
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thrombosis and inflammation
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1. To maintain proper posture, it is important to
a. sleep on the softest mattress possible b. avoid arching shoulders forward when sitting c. keep your knees locked when standing upright d. keep your stomach muscles relaxed to prevent back spasms |
B
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risks associated with exercise
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Cardiac injury, musculoskeletal injury, dehydration, temperature regulation
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People have a fear o triggering cardiac event
Rarely life-threatening Before starting a program get screen for underlying problems |
cardiac injury- risk of exercise
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High impact activities my pose risk for injury, but can be prevented if you gradually increase activity
Promote low impact exercise such as walking |
musculoskeletal injury
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Happens with prolonged exercise, warm temperatures, and health problems or medications
Water is best choice for hydration |
dehydration
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Hyperthermia occurs when pt exercises in hot climate and is often accompanied with dehydration
Body temperature rises, but skin is clammy and cold |
temperature regulations
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two types of gait
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antalgic, propulsive
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Limp to avoid pain when bearing weight on the affected side
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antalgic
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stooped, rigid posture, with the head and neck bent forward; movement forward is by small, shuffling steps with involuntary acceleration; also known as festinating gait; common in Parkinson’s.
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propulsive
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Mobility- Risk for impair skin integrity**
Activity Intolerance Impaired Physical Mobility Self-Care Deficit r/t Impaired Physical Mobility |
diagnosis for mobility
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things to remember when positioning patients
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a. Change of position every 2 hours
b. Proper alignment of hospital bed c. Incorporation of pillows, wedges, side rails, overhead trapeze, footboard, sandbags/trochanter rolls, splints d. Always use assistive devices and get help* |
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Pt who is immobile and cant ambulate or bear weight what should you do
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use assistive device and get help
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trochanter roll, abductor pillow, trapeze, foot board, hand and risk splints
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assistive devices
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i. Made from tightly rolled towels, bath blankets, or foam pads placed by the lateral aspect of the leg between the iliac crest and knees to prevent external hip rotation
ii. Prevents rotation of the hips and also shift position slightly |
trochanter roll
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Pt 400 lb- laying on right side for 2 hrs, just use this for small shifts
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trochanter roll
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i. Prevent internal hip rotation
ii. Done with person before or after hip rotations iii. Pressure areas can accumulate |
abductor pillow
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i. Someone who is immobile from the waste down (paraplegics)
ii. Use to reposition themselves or upper body exercise |
trapeze
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Device placed at the end of the bed to prevents plantar flexion or foot drop
Heels must touch board to be effective Common in pt who are comatose or in bed for a long period of time |
foot board
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Immobilize or if pt has a burn then the healing of tissue might scar and lose natural curvature so splints will keep hands aligned to prevent contractures.
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hand rolls/ risk splints
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Moving Up in Bed
Turning in Bed Logrolling- Friction-Reducing Devices |
moving pt in bed
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Spinal cord vertebral injury or suspected injury
Spinal cord injuries must stay flat, can only tilt whole bed Pt is moved in one unit in unison |
logrolling
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Prevents shearing
Types Transfer roller sheet Scoot sheets |
friction-reducing devices
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what position promotes respirations (90 degrees)
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high fowlers
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___for those who are obese or immobile must protect patients feet
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mechanical lift
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Do when Pt has immobility issues, at risk for atrophy and contractures
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Range of motion exercises
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when joint is fixated in one position and loses flexibility
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Contracture-
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Type of ROM
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active, passive, continuous passive
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1. Pt can help because they have some mobility
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active ROM
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1. Pt unconscious, comatose, paraplegic
2. No mobility 3. Nurse does all the motion for them |
Passive ROM
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1. Machine assistance with flexion and extension
2. Pt w/ knee surgery |
Continuous passive ROM
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when do we support joint and cradle distal/proximal portion as you are providing range of motion
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ROM exercise
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___ is associated with contracture formation and impaired mobility
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limited ROM
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If patient is going to fall; ____ with wide base of support so that they fall gently
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guide to floor
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Nurse should ***** for dependent edema and muscle atrophy of ___ patients
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immobilized
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