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135 Cards in this Set
- Front
- Back
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surgical wound infection develops and symptoms
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develops 4-5th day
fever,increased WBC's,tenderness and pain at the wound site, wound edges appear inflamed- purulent drainage present |
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classification of wounds
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incised-clean cut sharp with instrument
lacerated-jagged, irregular edges puncture-small opening in the skin(bullet stab) debridement-wounds do not heal because of infection operate to cut out infected tissue |
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wound drainage
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serous drainage-clear watery
sanguineous drainage-bright red-active bleeding serosanoguineous drainage-pale, red, watery mix of serous and sanguinous purulent drainage-thick yellow green tan or brown sign of infection |
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wound dehiscense & evisceration
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serious in abdominal wounds
obsese patients susceptible dehiscence-partial or complete separation at suture line everceration-total seperation of wound layers |
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fistula
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abnormal passage from an internal organ to the skin or from one internal organ to another
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purpose for maintaining wound undressed
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eliminate conditions that favor growth of organisms
allows for better observation & assessment avoid tape reaction avoid friction and irratation |
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purpose for dressing wounds
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prevent contamination
absorb drainage will support or splint wound site protect from injury promote homeostasis if pressure dressing |
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wound assessment
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inspect and palpate surrounding area
note edges note drainage and characteristics watch for signs of infection Braden scale |
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exudate
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fluid and cells that escape from blood tissues and are deposited in or on tissue surface
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granulation tissue
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new tissue found in wound that is highly vascular
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bedrest objectives
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healing & repair by reducing metabolic needs
reduces body need for oxygen reduces pain allows ill or debilatated to rest |
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risk factors for pressure ulcer
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immobility
chronic illness/ medications time/pressure phenomenon moisture age support surfaces alteration in nutrition & hydration low serum albumin increase temp(oxygen demands) infection(metabolic needs) paralyzed client-dont feel pressure obese-weight pressure |
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wound staging for pressure ulcers
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l. reddened area after 15 mins skin intact non-blanching erythema
ll. superficial break in skin abrasion or blister lll. break in skin subq, necrotic tissue noted, appear as crater lV. break in skin exposing muscle bone and supporting structures |
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braden scale factors
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sensory perception, moisture, activity, mobility, nutrition, friction shear
18 or below irsk |
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primary intention wound
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wounds with little tissue loss skin edges are approximate or close (surgical wound) |
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wound seperation post surgery
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3-14 days post op- technical complications
after 14 days- metabolic factors |
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3 phases primary intention
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inflammatory phase 1-4 days
epithelial proliferation and migration phase- 4-7 days reetablishment of the epidermal layers phase |
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secondary intention wound
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wounds with extensive tissue loss, edges cannot appoximate, injury is greater, takes longer to heal, chance of infection is greater |
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3 phases secondary intention
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inflammatory phase 1-3 days
proliferation phase-regeneration 3-24th day maturation phase-remodeling 21 days to months to year |
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third intention wound
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delayed wound closure process is deliberate by surgeon in order to allow drainage and cleaning of contaminated wound |
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Telfa dressing
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special gauze covering for incision line allows drainage to pass through and be absorbed by central layer
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transparent dressing
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occlusive dressing decreases risk for contamination
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hypertrophy
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increased muscle mass resulting from exercise and training
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atrophy
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muscle mass that is decreased through disuse or neurologic impairment
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immobility systemic effects
Metabolic |
negative nitrogen balance
calcium resorption altered protein metabolism risk for electrolyte imbalance altered exchange of nutrients and gases |
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assessment metabolic changes -immobility
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weight height
decrease serum protein increase BUN increase in serum calcium and phosphate |
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GI effects immobility
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constapation/impactions
anorexia appetite disturbance altered digestion & untilization of nutrients decreased peristalsis |
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assessment GI immobility
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BM activity
liquid fecal seepage intake and output skin assesment /turgor |
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respiratory changes in immobility
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atelectasis
hypostatic pneumonia |
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respiratory assessment and treatment
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check breath sounds and promote coughing and deep breathing every 1-2 hrs
check inspiration and exspriation-depth and rate auscultate lungs-wheezes crackles analysis of blood gases check for productive cough-increase fluis intake for thin secretions |
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cardiovascular changes in immobility
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orthostatic hypotension
thrombus formation increase workload of the heart-after proplonged immobility pooling of blood in lower extremities |
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immobility cardio assessments
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HR up BP down
edema DVT- homans sign calf circumference |
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urinary changes in immoblity
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urinary stasis, renal calculi
UTI assess for I & O, specific gravity(increased dehydration) WBC in urine above 100,000 urinary retention |
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urinary treament in immobility
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sit to void
adequate hydration 2-3000cc daily |
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psychosocial effect of immobility
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depression, behavioral changes, sleep/ wake disturbance impaired coping
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musculoskeletal changes immobility
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atrophy-foot drop
disuse-joint contractures/osteoporosis decreased muscle decreased joint mobility bone demineralization decreased endurance decreased stability pathological fractures |
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torticollis
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contracture of sternocleidomastoid muscle with head incline
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intervention for immobility problems
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body positioning
dorsiflexion-high top sneakers,footboard trapeze bar OOB weight bearing activity ASAP trocanter roll (hip rotation) independent ADL's aerobic isontonic and isometric exercises |
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treating pressure ulcer
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clean sore every day according to dr orders (wet to dry dressings)
use proper technique to dress wound obtain culture of the site keep moist to promote healing normal saline to cleanse and irrigate |
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central line
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vascular infusion device that terminates at or close ot heart or one of the great vessels
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types of central lines
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triple/multi-lumen catheter
PICC hickman catheter port a cath |
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central line considerations
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-don't take BP or perform venipuncture on arm with PICC
-use 10cc syringe to flush -check hospital policy/procedure -flush with normal saline |
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prevent central line infection
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handwashing
Chloraprep all direction 30 secs. scrub the hub assess site and patient maintenance of sterile and intact dressing |
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pain threshold
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-amount of pain stimulation a client requires before feeling pain
- -addiction-compulsive use of a substance tolerance-process by which the body requires a progressively greater amount of drug to achieve same results -physical dependence-biological need for substance |
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pain tolerance
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-maximum amount and duration a person is willing to endure
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-addiction
-physical dependence-biological need for substance |
-compulsive use of a substance
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tolerance-drug
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process by which the body requires a progressively greater amount of drug to achieve same results
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types of pain
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viceral(deep)- internal organs,crushing sensation from angina, burning of gastric ulcer
somatic-bone joint nerver receptors in skin or connective tissue superficial/cutaneaous-skin(needle prick,small cut) recurrrent acute-intermittent pain intractable-resistance to cure referred-perception of pain in unaffected area radiating-sensation of pain from initial site to another body part phantom-amptutee still feels arm neuropathic pain-burning sensation with shooting pain(peripheral nerves) psychogenic pain-emotional needs may prompt pain |
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nociceptors
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type of nerve receptor responsible for pain
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bradykinin
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potent pain producing chemical, powerful vasodilator, it increases capillary permeability & constricts smooth muscles
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allodynea
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head rush or brain freeze
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Perception-
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The point at which a person is aware of pain
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Transmission of pain-
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release of chemicals that sensitize the nerve endings, help transmit the pain message and signal as an impulse along the length of the nerve to the dorsal horn of the spinal cord and relay the signal to the thalamus and then to the cortex
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Prostaglandin
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increases the sensitivity of pain receptors by enhancing the pain-provoking effect of bradykinin
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Gate Control Theory-
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A way to understand pain relief measures; suggests that pain impulses can be regulated or even blocked by gating mechanisms along the Central Nervous System. These pain fibers can be stimulated, thus closing the gate.
Acupuncture works on the gate control theory |
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Nurse interventions to stimulate these gate pain fibers include:
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repositioning, backrubs using long strokes.
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Endorphins and Dymorphins:
(Neuromodulators) ( |
are produced at neural synapses at various points in CNS pathway and are powerful pain-blocking chemicals
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what do endorphins and dymorphins do
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• Body’s natural supply of morphinelike substances
• Activated by stress and pain • Located within the brain, spinal cord, and GI tract • Cause analgesia when they attach to opiate receptors in the brain |
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Assessment of Pain
The Fifth Vital Sign |
• Ask about pain regularly
• Assess pain systematically – use pain scale • Believe the client and family in their report of pain and what relieves it • Choose pain control options that are appropriate • Deliver interventions in a timely manner • Empower clients and families |
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physiological reaction to pain
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• Dilation of bronchial tubes and respiratory rate increased
• Increased heart rate/increased BP • Peripheral vasoconstriction • Increased blood glucose level • Diaphoresis • Increased muscle tension • Dilation of pupils • Decreased GI motility • Increased respirations |
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Parasympathetic stimulation pain- typically involving visceral organs
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• Pallor
• Muscle tension • Decreased heart rate and blood pressure • Rapid irregular breathing • Nausea and vomiting • Weakness and exhaustion |
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typical pain reactions
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Acute pain initiates sympathetic stimulation- pain of low to moderate intensity and superficial pain elicit the fight or flight reaction
• Dilation of bronchial tubes and respiratory rate increased • Increased heart rate/increased BP • Peripheral vasoconstriction • Increased blood glucose level • Diaphoresis • Increased muscle tension • Dilation of pupils • Decreased GI motility • Increased respirations |
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ABCDE method of pain assessment
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A- ask about pain regularly
B- Believe client and family C- Choose pain control options D- Deliver interventions in a timely fashion E- Empower client and family; enable them to control it as best as possible |
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P- What precipitated pain/what is pattern?
Q- Quality and quantity of pain; sharp, stabbing, aching, burning R- Region of pain- does it radiate S- Severity T- Timing of pain |
Use PQRST method of pain assessment
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Breakthrough pain-
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additional pain that may occur intermittently that is of rapid onset and greater intensity than the baseline pain
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Main objective with severe cancer pain is to prevent rather than treat the pain
It usually involves regular doses of opioid analgesics |
Cancer Pain
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Pain Management Interventions
Non-pharmacological : |
• Acupressure
• Acupuncture • Relaxation • Guided Imagery • Distraction • Progressive relaxation • Biofeedback • Self-hypnosis • TENS (transcutaneous electrical nerve stimulation • Cutaneous stimulation- • Anticipatory response |
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Opioids
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: morphine-like substances that produce systemic effects including pain relief and sedation
• Codeine, Morphine, Dilaudid, Duragesic, Oxycodone, Demerol |
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Normeperidine:
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an active metabolite in Demerol, causes neurotoxicity when it accumulates (PCA); Symptoms include anxiety, tremors, generalized seizures
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Demerol
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• Should not be used to treat prolonged pain
• Oral route is preferred when possible • Disadvantages of IM route include painful administration, unreliable drug absorption, sterile abscesses, and fibrosis of muscle and soft tissue • Repetitive dosing for pain control puts clients at high risk for above problems • Don’t give longer than 48 hours, 600mg/day • Suitable alternatives are Morphine, Dilaudid, Fentanyl, Oxycodone (oxycontin) |
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Epidural Anesthesia- PCEA
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• Take vital signs q15min; note respiratory rate; make sure catheter is secured to skin
• Side effects – respiratory depression, hypotension, n/v, pruritis, urinary retention |
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Transdermal Patch- (Fentanyl)
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•Patch is placed every 72 hours over non-hairy, nonedematous skin with good blood flow
• There is a delay in peak onset approximately 17 hours after applying first patch • Do not put on upper arm if mastectomy |
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Fentanyl pops or unit;
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Fentanyl pops or unit;
• Swab over oral mucosa to provide rapid absorption (usually 5-15 minutes) • Do not chew • Used to treat breakthrough pain • No more than 2 at a time • Allow to dissolve slowly |
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Medicating for Pain Relief
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• Assess for respiratory depression, use a sedation scale
• Sedation precedes respiratory depression • Prevention- do not allow pain to build • Don’t under medicate, consider the weight of the client • Evaluate pain relief, must reassess at ½ hour mark to evaluate for effectiveness • Medicate before client feels pain • Be aware of allergies • Schedule activities at height of effect of medication • Elderly have reduced sensory perception, so must assess |
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Chronic pain
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Usually long in
Duration Longer than 6 months Dull, Aching, Persistent, Diffuse Physiologic response: Often absent Relief of pain; sedation not desirable |
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Acute
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Usually Sudden Less than 6 months Sharp, Localized, May radiate Physiologic response: Initial increase in BP, HR, Sweating, Pallor Relief of pain; sedation often desirable; (expected) As needed or upon request |
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Rest
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–occurs when the individual is relaxed but not asleep
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Cyclical Nature of Sleep; 2 systems in the brain stem
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• Reticular activating system (RAS)- is partially responsible for LOC- contains special cells that maintain alertness and wakefulness
• Bulbar synchronizing region- ia area that releases serotonin to produce sleep- nor responsible for REM sleep |
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Sleep:
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• A cyclical physiological process that alternates with longer periods of wakefulness. The sleep-wake cycle influences and regulates physiological functions and behavioral responses
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Circadian rhythm
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• Circadies- about a day
• Temperature- up in late afternoon; down in early evening • Blood pressure- up at night; down in morning; down in sleep • Growth hormone- up at night; down during the day • Sleep- daily wake/sleep cycles |
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Biologic Rhythms:
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• Unique internal rhythm that guides the pattern of life’s processes
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Circadian synchronization-
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• occurs when an individuals sleep/wake patterns follow the inner biological clock (shift work, travel across time zones, irregular sleep/wake pattern
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Infradian rhythm:
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• Monthly cycle or longer
• menstrual cycle • Peptic ulcer- seasonal |
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NREM-
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slow waves; deep restful sleep-refers to sleep cycle that clients experience in a low stimulus environment
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REM-
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paradoxical sleep
Average person has 4-5 complete sleep cycles each night |
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NREM
Stage I |
• Transitional stage between wakefulness and sleep
• Twilight phase • One may think they are awake • Easily aroused • Involuntary muscle jerking may occur and wake the person • Active thought patterns • Lasts up to 30 minutes • Relaxed, drowsy, heart and respirations start to slow |
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NREM
Stage II |
• Light sleep, brain waves slow down
• Can be aroused with ease • Heart rate decreases further • Temperature may go down • Lasts 20-30 minutes |
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NREM
Stage III: |
• Involves initial stages of deep sleep or slow wave sleep (delta sleep)
• Sleeper is difficult to arouse and rarely moves • Muscles are completely relaxed • Vital signs decline but remain regular • Stage lasts 15-30 minutes |
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NREM
Stage IV: |
• Deepest stage of sleep
• Very difficult to arouse sleeper • Metabolism slows and body temp is low • If sleep loss has occurred, sleeper will spend considerable portion of night in this stage • Vital signs are significantly lower than during waking hours • Stage lasts approximately 15-30 minutes • Sleepwalking (somnambulism) and enuresis (bedwetting) may occur • Growth hormone secreted during this stage • Stage is responsible for restoring and resting body |
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REM Sleep- rapid eye movement sleep
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• Vivid, full color dreaming
• The more tired a person is, the shorter the paradoxical period • Begins about 90 minutes into the sleep cycle • Typified by rapidly moving eyes, fluctuating heart and respiratory rates and increased or fluctuating blood pressure • Irregular eye movements • Loss of skeletal muscle tone • Gastric secretions increase • Responsible for mental restoration • Duration of REM sleep increases with each cycle and averages 20 minutes and may last up to 60 minutes; stages 3 and 4 shorten • REM state in normal adults is 20-25% • During times of stress- REM sleep decreases in amount and tends to add to anxiety and stress |
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sleep cycle
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stage I -stage II-stage III-stageIV-stage III-stageII- REM-stage II
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Insomnia
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• Inability to get quality sleep
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Types of Insomnia:
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• Initial – cannot fall asleep
• Intermittent – cannot stay asleep due to frequent waking • Terminal- early awakening and inability to go back to sleep |
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Hypersomnia:
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• Excessive sleep; more than 9 hours, particularly during the day
• Sleep to noon; nap in the afternoon • Usually seen in depression |
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Sleep Apnea:
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• A disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer
• Interferes with deep sleep • Structural abnormalities Deviated septum Nasal polyps Enlarged tonsils |
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sleep apnea symptoms
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o Obstructive snoring
o Snores loudly o Drain in energy o Excessive daytime sleepiness (EDS)- most common o Affects work and school o May lead to cardiac arrest o Headaches after wakening |
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Sleep Apnea:
Treatment |
CPAP (continuous positive airway pressure); surgery
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Narcolepsy:
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• A dysfunction of mechanisms that regulate the sleep and wake states
• Excessive Daytime Sleepiness (EDS) • Assess- loss of muscle control; experiences frequent falls • Treatment: Stimulants; nap of 20 minutes or less, exercise programs, eating light meals • Avoid- long distance driving, long periods of sitting, hot stuffy rooms • This client is at risk for injury |
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Sleep Deprivation:
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• Causes include illness, stress, environmental disturbances, meds, shift work
• Involves decreases in the quantity and quality of sleep and inconsistency in the timing of sleep • Symptoms: blurred vision, fine moter clumsiness, decreased reflexes, slowed response time, decrease in judgment, confusion, irritability • Treatment is eliminations of factors that disrupt sleep patterns |
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Parasomnias:
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• Sleep problems more common in children
• Somnambulism- sleepwalking, night terrors, nightmares, enuresis-bedwetting; bruxism- grinding teeth • Client eats food but does not remember in the morning |
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Antiinsomnia agents:
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• Hypnotics- meds used to induce sleep
• Sedatives- produce a calming effect • Helpful when used correctly • Regular use can lead to tolerance and withdrawal syndrome • Benzodiazepines: alprazolam, diazepam, temazepam, zolopidem, triazolam |
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Presurre Ulcer
Wound Staging: |
• Stage I- reddened area not resolving after 15 minutes; skin is intact; may report tingling or burning; non-blanching erythema
• Stage II- superficial break in the skin to dermis; abrasion, blister; it may look like a shallow crater; superficial or partial thickness • Stage III- break in skin to subcutaneous tissue; necrotic tissue noted in subcutaneous layer; will appear as a deep crater; full thickness • Stage IV- break in skin exposing muscle and bone and supporting structures |
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Classification of wounds:
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Open wound- a break in the skin, superficial or deep- abrasion, laceration, puncture
Closed wound – no break in the skin- contusion, ecchymosis Partial thickness wound– involves the entire epidermis, part of the dermis, Full thickness wound– involves epidermis and dermis extending to subcutaneous tissue, possibly muscle and bone Non-infected wound- has not been invaded by pathogens Infected wound- has been invaded by pathogens Surgical wound – intentional wound made by surgeon for therapeutic purposes Pressure wound |
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Assessment of Urine
Volume |
• 60-120 ml/hr- depends on intake
• Less than 30 cc/hr =kidney malfunction • Polyuria= more than 2000 cc/day • normal = 1200-1500 ml/day |
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Urine Color
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• Straw to Amber
• Concentrated= dark amber • Red or pink = hematuria • Medication may discolor urine (azo-gantrisin) |
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Urine Clarity measures
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• Clear
• Cloudy- may be pus, (if left standing will become cloudy) • Foamy – may have protein |
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Urine Odor
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• Characteristic
• Sweet= diabetes • Offensive = pyuria (bacteria) • Foods- asparagus, garlic • Medications |
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Urine Retention
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- accumulate urine but inability to void
• Bladder holds up to 600cc the stimulated • Micturition reflex- usually occurs when 150-200cc • Retention is 1000-3000 cc –treatment is usually catheterization • Retention with overflow- void small amount but bladder is full; usually greater than 100cc; get dribbling • Stasis – slowing of urine flow- stagnation • Urine collects then stretches the walls causing pressure, discomfort and tenderness over symphysis pubis; S&S- restlessness, diaphoresis |
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Incontinence
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• Functional – involuntary unpredictable urination in a clent with an intact urinary and nervous system; immediate urge and not enough time to get to BR
• Overflow- loss of a small amount of urine from an overdistended bladder (20-30ml); dribbling • Reflex- loss of urine at predictable intervals, unaware of bladder filling lacks urge to void • Stress- leakage of small amount of urine caused by sudden increase in intraabdominal pressure (coughing, sneezing, laughing) • Urge- involuntary passage of urine after a strong sense of urgency to void; more often than every two hours |
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URINE
Vocabulary |
Incontinence – involuntary loss of urine
Retention- unable to void although there is enough urine in bladder. Treatment is catheterization Suppression- cannot void because kidneys are not secreting and bladder is empty. Diuresis – increased urine formation, usually from food Polyuria- excessive amounts of urine output Oliguria = diminished capacity to produce urine scant urine - 100-400 ml per day Anuria= inability to produce urine, less than 100 ml per day- same as kidney shutdown, renal failure,suppression Gluycosuria- glucose in urine Proteinuria- large amount of protein in urine Frequency- urinating more than usual – many intervals-less than every 2 hours Cystitis- inflamed or irritated bladder- will cause frequency Pregnancy- fetus putting pressure on bladder Nocturia – frequency at night that is not the result of increased intake Dysuria – pain or burning on urination |
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Fecal Charting
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• Color- usually brown (clay colored stools seen in gall bladder)
• In biliary disease feces will be white or clay colored due to absence of bile • Consistency- (formed, watery, hard) • Odor- client can tell if it has changed • Shape- shape of rectum • Blood- abnormal Black stool- blood in upper GI Bright red- lower GI Test – Hemaoccult - Hematest; stool for occult blood- use prepared slide or take small sample (1 inch) and place in cup; Prior to occult blood Client should avoid steak, veal salmon- it may cause false positive |
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Loss
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Loss can be death of a loved one, divorce, loss of independence
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Actual/physical loss
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Loss of a person or object; body part, family member, relationship, role at work
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Perceived loss;
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Loss that is uniquely defined by the grieving client- felt by individual but is intangible to others- loss of youth/financial/independence
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Maturational loss;
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Any change in the developmental process that is normally expected during a lifetime
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Situational loss;
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This includes any sudden, unpredictable external event- MVA
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Anticipatory loss;
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Type of loss when person displays loss and grief behaviors for loss that has yet to take place
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Psychological loss;
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Caused by altered self-image
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Grief;
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Is essential for mental and physical health
The emotional response to loss. It is manifested in a variety of ways- anger, sadness, guilt, regret |
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Bereavement;
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This state of grieving includes grief and mourning. It is the inner feelings and outward reactions of the survivor.
It does not proceed in sequential stages. An individual may move back and forth through a series of stages before the process is completed. A person does not get over a loss, but learns to live with a loss |
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Mourning;
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Period of acceptance of loss during which the person learns to deal with loss
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Theories of grief;
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Kubler-Ross’s stages of Dying; it is behavior oriented, and has five stages
• Denial- acts as though nothing has happened. May refuse to believe it has happened- or find it difficult to believe • Anger- individual resists the loss and may strike out at everyone and everything; this is the “why me” stage • Bargaining- individual postpones awareness of the reality of the loss and may try to deal with it as though it can be prevented; “I will do anything to change this” • Depression- individual may feel overwhelmingly lonely and become withdrawn; this is when bargaining fails • Acceptance- individual accepts the loss and begins to look to the future |
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Bowlby’s Phases of Mourning:
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• Numbing- may feel stunned or unreal- may last hours to a week or more
• Yearning and Searching- acute distress, emotional outbursts- may last months or years • Disorganization and Dispair- may examine how and why loss occurred • Reorganization- will begin to accept new role, acquire new skills, build new relationships |
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Worden’s Four Tasks of Mourning:
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• Task 1- Accept reality of loss
• Task 2- Work through the pain of grief • Task 3- adjust to the environment in which the deceased is missing • Task 4- emotionally relocate the deceased and move on with life |
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Normal Grief-
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uncomplicated, consists of normal feelings, behaviors and reactions to loss
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Anticipatory Grief-
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the process of disengaging or letting go that occurs before an actual loss or death has occurred. At time the grief process takes place before the actual moment of death.
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Complicated Grief-
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occurs when the client has difficulty progressing through the normal stages or phases of grieving. Bereavement becomes complicated and loss never resolves.
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Disenfranchised Grief-
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occurs when a loss is experienced and cannot be openly acknowledged or extends over a lengthy period; has difficulty expressing feelings of loss
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Documentation of End of Life Care
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• Time of death
• Who pronounced the death of client • Any special preparation • Who was called and who came to hospital • Personal articles left on client • Personal items given to family • Time of discharge to morgue • Location of name tags on the body |
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Palliative Care:
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• The active and total care of clients whose disease is not responsive to curative treatment
• The goal is achievement of the best possible quality of life for clients and their families • Care is focused on enhancing the quality of remaining life by integrating physical, psychological, social and spiritual aspects of care • Clients are eligible for palliative care even though they are also receiving curative treatment • An important requirement for a nurse in palliative care is to communicate effectively with clients and families |
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Hospice
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• It is a program of care provided across a variety of settings and based on the understanding that dying is a part of the normal life cycle. It promotes the idea of “living until you die”
• It provides comprehensive medical and supportive services, not just pain relief • Most have to have 6 months or less to live • It is family centered |
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Places where hospice may be found
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• Acute care hospital-special unit
• Long term care facility-special unit • Special facility • Home care • There is an interdisciplinary team of doctors, nurses, social workers, clergy, volunteers |
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Clinical Signs of Death
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• Irreversible cessation of circulatory and respiratory functions
• Irreversible cessation of all functions of the entire brain, including the brain stem • Lack of reflexes • Flat EEG • Pupils fixed and dilated • Nursing responsibilities o Care of the client’s body o Care of the client’s family o Legal responsibilities- pronouncement of death by MD |
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Characteristics of Pain
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• Onset and duration
• Location • Intensity- described as mild, moderate, severe; use pain scale • Precipitating or aggravating factors • Relief measures- changing position, eating, applying heat, rocking, immobility • Quality- might use any of following terms; ask “what does pain feel like” • Concomitant symptoms- what symptoms does client have with pain ie. Headache, dizziness etc • Influence on ADL- interfere with sleep- can client dress self |
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Behavioral Indicators of Pain
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• Vocalizations: moaning, crying, gasping
• Facial expressions: Grimace, clenched teeth, lip biting • Body movement: restlessness, guarding, muscle tension, drawn up knees, writhing, rocking • Emotions: excitement, irritability, extreme quietness, avoidance of conversation, focus only on activities for pain relief |
