Exam 1 Flashcards
Stress definition
response to challenges (it doesn’t have the resources for), different for everyone
Stress neutral
coping effective, ex. a paper cut
Challenge/manageable stress
coping effectively but may need new coping skills, ex. big cut on your leg and learn to apply pressure
Stress not manageable
ex. degloving skin (comes off hand), need outside help
Chart of stress response starts with a ____, triggering ______ to release _____
stressor
hypothalamus response
corticotropin releasing factor
Stress response goes down what three paths
Sympathetic nervous system
Anterior Pituitary gland
Posterior Pituitary gland
sympathetic nervous sys activation path of stress
norepinephrine, epinephrine, dopamine (flight or flight) –>
increasing: HR, BP, CO, blood glucose, blood perfusion to muscle; bronchial dilate, pupils dilate,
anterior pituitary path of stress
ACTH –> adrenal cortex –> aldosterone (increase Na and water) or cortisol (increase: protein synthesis, blood glucose, BP, CO, anti-inflammatory, immunosuppression)
prolonged response, at risk to be sick
posterior pituitary path of stress
ADH –> water retention
General Adaptation Syndrome stages and info
alarm, resistance, and exhaustion
several body systems respond immediately to the stressor
goal to return to homeostasis
alarm stage
CNS aroused, fight or flight
resistance stage
PNS, try to go back to normal, resist stress, repair damage,
exhaust stage
no resources left, high BP, depression (health issues)
positive stress called
eustress
negative stress called
distress
Transactional Theory of Stress and Coping
two stages of appraisal (primary and secondary) before responding
primary: does it pose a threat (stop if no)
secondary: can we cope? do we have resources?
Sources of stress
Physiological
Psychological
Physiological stress ex.
car accident, chronic illness
Psychological stress ex.
divorces, family problems
Types of Stress
Acute Stress
Episodic acute stress
Chronic Stress
Acute Stress
most common, brief, pos or neg, fight or flight
Episodic acute stress
frequent episodes of acute stress, affects relationships
Chronic Stress
constantly wears on pt, uses all the resources up
Cognitive appraisal meaning
what/how you view stress
Cognitive appraisal aspects
Age Developmental level Maturation Environment Life experiences General mental and physical health status
Consequences of Chronic Stress on CNS
continuous activation, headache, irritable, anxiety
Consequences of Chronic Stress on Cardiovasc
incre HR, BP
Consequences of Chronic Stress on Immune sys
lower WBC, asthma, arthritis
Consequences of Chronic Stress on Musculoskel
knots in neck/shoulders
Consequences of Chronic Stress on GI
IBS, ulcerative colitis
Consequences of Chronic Stress on Integumentary
hair loss, acne
Consequences of Chronic Stress on Reproductive
ED, decrease sperm
menstrual issues
Risk for psychological stress
Problems w/relationships Strained family relationships Financial strain Job stress/insecurity Food insecurity
Risk for physiologic stress
Significant injury or illness
Chronic pain
Acute stress s/s
headache, trouble focus, GI issue, irritable, increase HR, dilate pupils
Chronic stress s/s
infections, slow wound heal, unintentional weight loss, increase blood glucose, depression, high BP, change in sleep
Denial
Refusal to accept reality to avoid the emotional impact
Rationalization
Justify/explain bad behaviors to avoid emotional discomfort or save face
Projection
Attribute negative feeling onto someone else
Repression
Conceal bad thoughts or memories to try to forget about them
Regression
Movement back to a more comfortable developmental time in life
Compartmentalization
Categorize life experiences to avoid facing the anxieties while in that mindset
Clinical Management: Primary Prevention
try to prevent illness as a result of stress
promote effective coping, nutrition, exercise, social support, self-esteem
Problem- focused coping
try to eliminate stressor
Emotion- focused coping
control our emotional response to it
ex. journal, walk
Meaning- focused coping
find meaning behind stress
ex. religion
Common positive coping strategies
Education Social support Exercise Therapeutic lifestyle change Music therapy Relaxation strategies Alternative therapies
Ineffective and maladaptive coping responses
Appropriate but insufficient Use or abuse of alcohol or other substances Smoking Overeating Denial Avoidance
Pharmacologic Therapy used for stress do what
treat the s/s not the stress
Crisis
threatening situation trigger by an event causing a body response
Situational stressors
personal, family, work-related
ex. chronic illness, financial strain, motor vehicle accident, death of a loved one, change in marital status, unwanted pregnancy
Developmental stressors
occurs as the person moves through the stages of life
ex.
Kids (physical appearance, family, friends, school)
Adolescents (friendships, belong, identity formation, leaving home)
Adults (marriage, family, career, aging)
Older adults (health problems, mobility, cognition)
Adventitious stressors
disaster events, rare and unexpected
ex. natural disasters, physical/sexual assault, terrorism
Socioeconomic stressors
stressors that occur from poverty, SES, and homelessness
Cultural stressors
living in a society they do not fit in culturally or receiving care that ignores their cultural beliefs
Nursing process
Assess, Diagnosis/Analyze, Plan, Implement, Evaluate
A nurse is caring for a client who has migraine headaches and reports that they are “getting worse”. Which of the following questions should the nurse ask the client to determine if the headaches are stress-related disorders (select all that apply)
What is the intensity of your migraines
How often do the migraines occur
Are you eligible for workers compensation due to the migraines
What type of support is available to you when you have a migraine
What coping strategies do you use when you experience a migraine
What is the intensity of your migraines
How often do the migraines occur
What type of support is available to you when you have a migraine
What coping strategies do you use when you experience a migraine
A nurse is caring for a client who has delivered a healthy newborn. The client is tense, refuses to hold the baby, and tells the nurse, “I have no idea how to handle having a baby. I wish this pregnancy had never happened”. Which of the following statements should the nurse make
Becoming a parent is a new experience for you. Let’s talk about your concerns
You should be thrilled about having a newborn. I would be
Why don’t you hold the baby? I’m sure it will make you feel better
How can you think that way? This is a joyous occasion and should be celebrated
Becoming a parent is a new experience for you. Let’s talk about your concerns
A nurse is talking about implementing self-care strategies to cope with the stress of caregiving with the partner of a client who has dementia which of the following strategies reported by the partner should the nurse identify as an example of effective coping
Practicing deep breathing while sitting outside
Sitting by the clients bedside and drinking coffee
Going out onto the patio to smoke a cigarette when feeling stressed
Drinking a glass of wine every night before falling asleep
Practicing deep breathing while sitting outside
A nurse is planning care for a client who recently divorced with two young children. the client reports difficulty sleeping, feeling hopeless, and being estranged from the family. the nurse should plan to monitor the client for which of the following potential manifestations of chronic stress.
Systemic infection
Exaggerated startle response
Recurring nightmares
Suicide
Suicide
A nurse in a community clinic is interviewing a client who is in distress and reports being unable to sleep following a neighborhood fire several days ago. The client has hypertension, tachycardia, and is diaphoretic. The nurse should identify that the client is experiencing which of the following types of stress
Acute stress
PTSD
Episode acute stress
Chronic stress
Acute stress
A nurse is caring for a client who has been charged with partner violence against their spouse. The client is angry, pacing, and yells out, “I wouldn’t lose my temper If my spouse would just leave me alone. It’s their fault. “ the nurse would identify the client is displaying which of the following defense mechanisms
Projection
Compartmentalization
Repression
Regression
Projection
A nurse is conducting an educational session for client to report experiencing stress-related disorders. A client asks the nurse which part of the body activates the stress response. Which of the following responses should the nurse provide
Sympathetic nervous system
Adrenal glands
Hypothalamus
Adrenocorticotropic hormone
Hypothalamus
A nurse is interviewing a client who is in distress and tell the nurse, “my ex-partner is suing for full custody of my children. I am so worried and don’t know what to do.” which of the following questions should the nurse asked to evaluate the client coping skills
can you describe your relationship with your ex partner
what happens when you feel worried like this
what do you believe with your contribution to the relationship break up
what strategies have you used in the past to do with stress
what strategies have you used in the past to do with stress
A nurse is providing discharge teaching about health promotion to a client who has a new diagnosis of type 2 diabetes mellitus. which of the following instructions should the nurse include. (select all that apply)
Practice mindful breathing Start each day with a to-do list Include simple carbohydrates in the diet Develop habits to mitigate stress Preserve energy by reducing physical activity
Practice mindful breathing
Start each day with a to-do list
Develop habits to mitigate stress
A nurse is caring for a client who has delivered a healthy newborn. The client tells the nurse that while they are somewhat stressed about being a new parent, they are thrilled by the birth of their child. The nurse should identify that the client is experiencing which of the following types of stress
Allostatic load
Distress
Eustress
Fight or flight response
Eustress
A nurse is caring for a client who is in crisis following the Break-Up of a long-term relationship. The client tells the nurse, “I might as well just die. My life is over.” Which of the following actions should the nurse take first
explore past positive coping strategies
establish a follow-up plan of care
conduct a suicidal risk evaluation
display a neutral attitude
conduct a suicidal risk evaluation
A nurse is caring for an older adult client who reports being stressed about their health status due to problems with short-term memory oh, slow reaction times when driving, and urinary frequency. The nurse should recognize that the client is experiencing which of the following types of stressors
developmental stressors
situational stressors
adventitious stressors
socioeconomic stressors
developmental stressors
A nurse is assessing a client who is working at home due to covid-19 restrictions. The client reports abdominal cramping and bloating diarrhea and states, “I’m completely stressed out from working at home.” the nurse should identify that the client is experiencing manifestations of which of the following stress related conditions
irritable bowel syndrome
food poisoning
panic disorder
major depressive disorder
irritable bowel syndrome
A nurse is caring for a college student admitted for acute alcohol intoxication. The client reports feeling overwhelmed and expresses an inability to cope with stressors at school. Which of the following statements should the nurse make
Drinking too much alcohol is not the best choice. I suggest you stop
I can see why you’re using alcohol to cope; you’ve got a lot going on
Let’s talk about the coping methods that have worked for you in the past
I’ve been stressed before too but I tell myself that I can handle it
Let’s talk about the coping methods that have worked for you in the past
A nurse is interviewing a client who recently experienced in Act of workplace violence when an armed person how the workers at gunpoint before the police intervened. The client now reports being anxious and fears the gunman might return. The nurse should identify that the client is experiencing which of the following types of crisis
Situational
Cultural
Maturational
Adventitious
Adventitious
A nurse is caring for a client who reports experiencing stress over an upcoming surgical procedure. Which of the following statements describe the characteristics of stress
Stress is an easily defined phenomenon regardless of viewpoint and discipline
Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one state of equilibrium
Stress only affects the individual and does not affect the person’s family, friends, or other associates
The lack of definition regarding stress does not pose a problem for the client or the nurse
Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one state of equilibrium
A nurse is caring for a client who has pancreatic cancer that is unresponsive to treatment. The client is experiencing significant weight loss and fatigue, but when the nurse asked how they are feeling, they respond with, “great I’m going to beat this cancer.” which of the following defense mechanisms is the client using
Regression
Projection
Repression
Denial
Denial
A nurse is caring for a client who has pancreatic cancer that is unresponsive to treatment. The client is experiencing significant weight loss and fatigue, but when the nurse asked how they are feeling, they respond with, “great I’m going to beat this cancer.” which of the following defense mechanisms is the client using
Regression
Projection
Repression
Denial
Denial
A nurse in a health clinic Is interviewing a client who is upset and reports that their stress is “too much to handle.” The client is unemployed, a single guardian to young children, and has periodic asthma attacks. Which of the following stress related conditions is the client experiencing
PTSD
Allostatic load
Chronic illness
Alarm stage
Allostatic load
A nurse is caring for a client whose partner was recently hospitalized with covid-19. The client is experiencing manifestations related to the alarm stage of General Adaptation Syndrome. For which of the following manifestations should the nurse monitor (select all that apply)
hypertension dilated pupils increase state of arousal bradycardia lethargy
hypertension
dilated pupils
increase state of arousal
A nurse is assessing a client who was sexually assaulted six months ago and has been diagnosed with PTSD. Which of the following manifestations should the nurse expect (select all that apply)
intrusive memories of the event flashbacks of the event poor work relationships exaggerated startle response when reminded of the event frequent episodes of diarrhea
intrusive memories of the event
flashbacks of the event
exaggerated startle response when reminded of the event
What are some reasons it is important to understand the med that we are administering
Can question an order if you think it is wrong (pt safety)
Providers are humans and can make mistakes
Can answer pt questions
Drug categories
Similar: act, therapeutic effects, ADR, contraindications, precautions
Allergic to one, likely allergic to all
Sometimes have outliers though
Generic name
Given by company who created it
Not capitalized
Brand name
Drugs commercial name
Capitalized
Rates of absorption of oral med (quickest to slowest)
liquid, suspension, powder, capsule, tablet, coated tablet, enteric-coated tablet
Enteric-coated (EC)
released in the intestine
Extended-release (ER) or Sustained-release (SR/XR)
doesn’t release right away, slow
Immediate-release (IR)
released right away
Scored tablet
line that goes across pill to cut it in half
has to have the line to cut it
Parenteral meaning
Injectable drugs
Parenteral routes
IV, IM, sub-Q
Intravenously (IV)
Absorption: immediate
Onset of action: immediate
used when they already have an IV in pt
Intramuscular (IM)
Absorption: varies (rapid if water-soluble, rapid if good circulatory flow)
Onset of action: varies
a little faster than sub-Q cause of increase blood flow
Subcutaneously (sub-Q)
Absorption: varies (rapid if water-soluble, rapid if good circulatory flow)
Onset of action: varies
Transdermal routes/places
skin, eyes, ears, nose, rectum, vagina, lungs
Transdermal info
fast
constant amount of drugs over an extended time
slow onset
long duration of action
Pharmacokinetics
describes the absorption, distribution, metabolism, excretion of the drug
Absorption
movement of administration site to various tissues
Distribution
movement of a drug by the circulatory system to the intended site of action
depends on blood flow
Metabolism
a change in the drug that may make it more or less potent, soluble, or inactive
usually occurs in the liver
if liver problems, build-up of toxins
Excretion
elimination
ex. feces, urine, sweat, exhaled air
if kidney problems, can’t rid of it and build-up of toxins
First pass effect
Before it is in the blood in circulation, some drug is lost
Oral drugs
Drug half-life
Takes time for a drug to decrease in amount by half
Med with a long half-life don’t give often since they last long
Half-life won’t be as fast if pt has liver/kidney problems
Drug half-life
Takes time for a drug to decrease in amount by half
Med with a long half-life don’t give often since they last long
Half-life won’t be as fast if pt has liver/kidney problems
Onset
Amount of time it takes to demonstrate a therapeutic response
Starts to help
Peak
Amount of time to achieve a full therapeutic effect
Completely helps with the issue
Duration
Amount of time the drugs therapeutic effects last
The whole time the med last
Peak vs Trough
Peak- highest level
Trough- lowest level
Therapeutic level
Space between peak and trough
Drug levels needed in pt
Need to be in a therapeutic level so you can help with the issue
If too low can lead to resistance
If too high can injury body
When is peak lab drawn
1hr and a half after administration
When is trough lab drawn
30 mins before administration
Pharmacodynamics
biochemical changes that occur in the body as a result of taking a drug
Agonists
drugs that bind with a receptor and increase the typical response
works with what the body is doing and increases it
Antagonists
drug that binds with a receptor and either blocks or inhibits a typical response
like an umbrella, blocks most of the receptors but not all
Expected action
What we expect to happen in response to a specific drug
Ex. give acetaminophen which will reduce pain, fever, fatigue
Therapeutic uses
Why we are giving the pt the med
Ex. give to reduce headache (even though it helps with other s/s as well)
Adverse drug reactions (ADR)
nontherapeutic and unintended
Ex. of mild and severe ADR
mild- nausea, itchy, dizzy
severe- anaphylaxis, convulsions
Drug tolerance
decreased response to a drug over time or repeated use
may need to increase dose to get the same body response as before
Drug cumulative effect/drug sensitivity
body can’t excrete existing dose before another dose is given
can lead to toxicity
may be caused by a metabolic change in the body (liver/kidneys)
Liver lab test
AST- 0-35 ul
ALT- 4-36 ul
Liver lab test
AST- 0-35 ul
ALT- 4-36 ul
Kidney lab test
BUN- 10-20 mL/deciL
Creatine- male 0.6-1.2 mg/deciL or female 0.5-1.1 mg/deciL
Drug toxicity
excessive doses resulting in a negative physiologic effect
can be a result of impaired excretion
important to monitor drug serum levels
Drug toxicity
excessive doses resulting in a negative physiologic effect
can be a result of impaired excretion
important to monitor drug serum levels
What to do to avoid drug toxicity
Prescribe lowest dose that achieves therapeutic effect
Precautions
Use drug when benefits outweigh risk
Know why pt is taking it, precautions that go with it, diet restrictions, physical assessments that need to be done
Contraindications
potential to cause serious ADR in relation to a specific factor
ex. specific foods, combination of certain meds, certain populations
Interactions
can change the action of the drug in the body (absorption, metabolism)
can be drug-drug or drug-food
Types of drug interactions
additive
synergistic
antagonistic
Additive effect
Effects add together and cause the same action, do not influence each other
Synergistic effect
Effect of one drug are greater w/another, increase each other
Antagonist effect
Effects of one drug are decreased or stopped w/another, counteract
Grapefruit juice does what to certain drugs
slows down metabolism of some drugs
decreases enzymatic activity
Dark greens (vit k) does what to certain drugs
counteracts anticoagulant effects of warfarin
Considerations for breast feeding (with drugs)
baby weight, will it pass through milk, will it negatively affect baby
Considerations for infants (with drugs)
weight, big head, large surface area, less acidic stomach
Considerations for older (with drugs)
body doesn’t work as well, slow stomach
Considerations for pregnancy (with drugs)
affects baby, teratogenic (harm to the fetus in utero)
Client instructions for drugs
purpose, generic vs. brand name, need to know the route, administration schedule, potential ADR (to know what to expect), precautions (ex. don’t drive while using)
Prescription drugs
drugs that are prescribed by a provider and can be harmful without supervision
Nonprescription drugs/Over the counter (OTC)
drugs that are relatively safe to talk without supervision
A patient talking SMZ/TMP asks the nurse what the name means. The nurse replies sulfamethoxazole is combined with trimethoprim in SMZ/TMP to help drug effectiveness. How does this work?
SMZ has a synergistic effect with TMP against gram pos and neg
SMZ acts along with TMP as an anesthetic
SMZ increases the excretion of TMP thereby increasing the response in the bladder
SMZ is highly protein bound and displaces TMP
SMZ has a synergistic effect with TMP against gram pos and neg
When a drug binds to a receptor to produce a pharmacologic effect, the drug may be called
Agonist
Accelerator
Antagonist
Blocker
Agonist
Which organ does drug metabolism usually occur in?
Heart
Stomach
Liver
Brain
Liver
The peak is the amount of time the drug
Needs to produce an initial response
Needs to reach its highest effective concentration
Need to change into active metabolites
Is in the therapeutic range
Needs to reach its highest effective concentration
A patient requires a high dose of a new antihypertensive medication because the new medication has a significant first-pass effect. What does this mean?
The med passes through the renal tubules and is excreted in large amounts
The med is extensively metabolized in the pt liver
The med must pass through the pt bloodstream several times to generate a therapeutic effect
The med is ineffective following the first dose and increasing effective with each subsequent dose
The med is extensively metabolized in the pt liver
Which of the following circumstances will increase the rate of drug absorption for a subcutaneous injection
Large surface area
Large muscle mass
Low blood flow
Lipid solubility
Large muscle mass
Which is safer to use when referring to a drug
generic or brand
generic (only one generic name vs multiple brand names)
When performing an assessment to determine which med can be used, which of the following elements is most important?
Presence of illness
Allergies
Physical examination
Weight
Allergies
When two drugs given together have an effect equal to the sum of their respective effects, the interaction is
Antagonized
Additive
Agonist
Potentiated
Additive
An unintended effect of the drug is
Toxic reaction
Side effect
Allergic reaction
Adverse effect
Adverse effect
Indications (drugs)
information on condition and diseases for which the drug is used for
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Pain definition
whatever the experiencing person says it is
most reliable indicator of pain
issue when someone is unable to verbalize it
Acute pain
short term (less than 3 months) usually know what caused it try to minimize side effects
Chronic pain
long term (more than 3 months or longer than it should be for the specific injury)
may not know what caused it (etiology)
want people to be lowest possible level
Nociceptive
normal pain or response to injury (protective)
tissue injury
dull, aching, poorly localized
Somatic pain
bone, joint, muscle, connective tissue
Visceral pain
organ, (could also mean emotional)
Cutaneous pain
skin
Transduction
noxious stimuli cause cell damage which releases chemicals (prostaglandins, bradykinin, serotonin, substance P, histamine)
activates nociceptors causing action potential
Transmission
Action potential goes from injury, spinal cord, brainstem, thalamus, cortex to processing
Perception
the conscious experience of pain
Modulation
neurons in brainstem go down spinal cord and release substances (ex. endorphins, enkephalins) to stop nociceptive impulses
Neuropathic
pathology or disease of the somatosensory system, communication issue, not processing sensory input
shooting, tingling, burning, numbness
Mixed pain
combination between nociceptive and neuropathic
Psychosocial consequences of untreated pain
fear, anger, depression, anxiety, difficulty maintaining relationships
Cardiovascular response and s/s to untreated pain
increase: HR, CO, peripheral vascular resistance, myocardial O2 consumption, coagulation
HTN, unstable angina, MI, DVT
Endocrine and Metabolic response and s/s to untreated pain
increased: ACTH, cortisol, ADH, epinephrine, norepinephrine, renin, aldosterone
decreased: insulin
gluconeogenesis, glycogenolysis, muscle protein catabolism
weight loss, increases RR and HR, shock, glucose intolerance, hyperglycemia, fluid overload, HTN, urinary retention, decrease urine output (f/f s/s)
GI response and s/s to untreated pain
decreased gastric and intestinal motility
constipation, anorexia, paralytic ileus
Immunologic response and s/s to untreated pain
decreased immune response
infection
Musculoskeletal response and s/s to untreated pain
muscle spasm, impaired muscle function
immobility, weakness, fatigue
Neurologic response and s/s to untreated pain
impaired cognitive function
confusion, impaired ability to think, reason, and make decisions
Renal and urologic response and s/s to untreated pain
decrease urine output, urinary retention
fluid imbalance, electrolyte disturbance
Repiratory response and s/s to untreated pain
decreased: tidal volume, cough, sputum retention
hypoxemia
atelectasis, pneumonia
Infants and kids at risk for pain because
cant communicate, immune system might not be fully developed, people don’t always listen to them
Older adults at risk for pain because
cognitive decline, cant verbalize or choose not too, don’t want to lose independence, more health issues
Gender info related to pain
women more likely to report pain, have a lower threshold
SES info related to pain
might not have access/be able to afford care
Cultural info related to pain
some may feel pain is necessary (suppose to feel a lot), some may feel it is not acceptable to admit they are in pain
Substance abuse risk factors in related to pain
providers may not want to prescribe them meds, might have a tolerance to meds
Individual risk factors that place pt at a higher risk for pain
chronic conditions, acute or traumatic injury, medical procedures
fatigue affecting pain experience
more pain when tired
cognitive function pain experience
not understanding what is going on, may experience more pain
prior experiences affecting pain experience
if pt had bad pain w/ an issues before, next time they have that issue they may be very worried and in more pain
anxiety and fear affecting pain experience
if a pt is already worried about the pain, may be experience more
Elements of pain assessment
location,
intensity (scale),
quality,
onset and duration (and what were you doing),
relieving factors,
function goal (what number show the pain be at to function)
Pain scale info to know
use the same pain scale every time (not always true in practice)
faces scale for 3yr and younger and cognitive impaired
number scale for 8yr and older
Behavioral signs of pain
facial expressions (grimace), restlessness (cant sleep, changes spots a lot), change in activity (usually decrease), crying, assessment tool
Nonpharm strategies to help treat pain
massage, repositioning and body alignment, splinting (hold pillow against incision), thermal interventions, mind-body therapies, exercise, TENS, acupuncture
Can non pharm strategies replace pharmacology strategies
usually they don’t
Nursing care to treat pain
schedule pain interventions PRN,
review orders for analgesia,
give pain meds before pain levels get very high,
have pt report pain,
create plan w/ more pharm and non pharm interventions
Meds do target what to deal with pain
Target opioid receptors
Types of opioid receptors
mu, kappa, delta
Mu receptors
stimulated by opioid drugs
pos effects: analgesia
neg effects: euphoria, sedation, decrease RR, physical dependence
Kappa receptors
stimulated by a lesser extent to opioid drugs
pos effects: some analgesia
neg effects: sedation, hallucination, delusion
Types of analgesics
NSAIDs (1st and 2nd gen), acetaminophen, opioids, centrally acting nonopioids
COX (Cyclooxygenase)
produces inflammatory response
enzymes convert arachidonic acid into prostaglandins and other compounds
COX-1
homeostasis
protects gastric mucosa, enhance platelet aggregation, renal perfusion
COX-2
response to injury
inflammation, pain, fever
Types of 1st gen NSAIDs
aspirin (ASA), ibuprofen (Advil, Motrin), naproxen, aleve, indomethacin, ketorolac
1st gen NSAID Pharm Action
COX-1 and COX-2 inhibitor
decrease: pain, inflammation, temp
anticoagulant, impairs renal perfusion, gastric mucosa not protected
1st gen NSAIDs ADR
gastric upset, heartburn, nauseas, gastic ulcers, bleeding tendencies, renal dysfunction, Reye’s syndrome (swelling in liver and brain in kids after viral infection
1st gen NSAIDs Interventions
monitor s/s of bleeding and easy bruising petechiae,
may need to use proton pump inhibitor,
monitor I&O,
do labs: BUN and creatine,
monitor tinnitus, dizzy, headache
abd pain, hematemesis, coffee-ground emesis
red, black or tar stool
1st gen NSAIDs Admin
swallow whole (enteric-coated or SR) stop 1 week before surgery
1st gen NSAIDs Client Instructions
take w/ food or milk avoid alcohol report s/s bleeding changes in urination sudden weight gain, edema stop taking if: ringing in ears, dizzy, unwarranted sweat
1st gen NSAIDs Contraindication/Precaut
pregnancy, peptic ulcer disease, bleeding disorder, pre-op, older adults, ETOH abuse, H. pylori, HTN, kids w/viral infection, heart fail, renal dysfunc
1st gen NSAIDs Interactions
aspirin and anticoagulants (both incre bleed), aspirin and NSAID, ACE inhibitors (both incre renal dysfunc)
2nd Gen NSAIDs name
celecoxib (Celebrex)
2nd Gen NSAIDs Pharm Action
COX-2 inhibitor, suppress pain inflammation and fever, decrease gastric effects, increase risk for CV issues (vasoconstrictor and platelet aggregation)
2nd Gen NSAIDs Intervention
monitor s/s of GI bleed may need proton pump inhibitor monitor I&O monitor lab: BUN, creatine monitor s/s for MI (left arm hurt, impending doom, jaw pain) and CVA (slur speech, face droop)
2nd Gen NSAIDs Client Instructions
take a w/low dose of ASA, and food or milk
avoid alcohol
report s/s GI bleed
changes in urination
sudden weight gain
report: chest pain, short of breath, severe headache, s/s stroke
give 2 hours away from Mg or Al antacids
2nd Gen NSAIDs Contraindication/Precaut
pregnancy, kidney or liver impairment, GI bleeds, anemia, ETOH abuse, asthma
2nd Gen NSAIDs Interactions
Lasix (decre the diuretic effect of Lasix), fluconazole (can incre its levels), anticoagulants (both)
Acetaminophen Pharm Action
nonopioid analgesic (mild to moderate pain), COX inhibitor, fever reducer,
Acetaminophen ADR
liver damage (if take too much) HTN (mainly in women or those taking it daily)
Acetaminophen Admin
can be given oral, rectal, IV
max 4g per day
Acetaminophen Interventions/Client Instructions
avoid more than 4g a day
report/monitor: abd discomfort, N/V/D, sweating
take BP
Acetaminophen Contraindication/Precau
ETOH abuse
use w/ caution: anemia, hepatic or renal disease, immune suppression (may mask infection)
Acetaminophen Interactions
alcohol
warfarin (incre risk of bleed)
Centrally Acting Nonopioid name and pharm action
tramadol (Ultram), for moderate to moderately severe pain
binds to select opioid receptors, blocks reuptake of norepinephrine and serotonin
Centrally Acting Nonopioid ADR
sedation, dizzy, headache, nausea, constipation, seizure, urine retention
Centrally Acting Nonopioid Interventions
monitor ambulation (dizzy)
give w/food and antiemetic (nausea)
measure VS and give opioid antagonist when RR falls
Monitor s/s seizures, have suction equipment ready
monitor for urinary retention
fluid, fiber, movement (constipation)
Centrally Acting Nonopioid Admin
onset is 1 hr (give before pain is high level)
ER so swallow whole
Centrally Acting Nonopioid Client Instructions
Avoid before driving
Sit if lightheaded/change positions slowly
fluid, fiber, movement when constipated
Only take PRN
Centrally Acting Nonopioid Contraindication/Precau
acute ETOH, opioids, psychotics drugs (both depress)
seizure disorder
respiration depression
Centrally Acting Nonopioid Interactions
MAOIs risk for hypertensive crisis
SSRI
Tricyclic antidepressants
CNS depressants
Opioid Agonist vs Opioid Agonist-Antagonist
increase response, mimic action of natural opioids
decrease mu and increase kappa
Opioid Agonist types
morphine, fentanyl, demerol, methadone
Opioid Agonist Pharm action
analgesia
binds with mu receptor
Opioid Agonist ADR
respiration depression, sedation, dizzy, lighthead, drowsy, constipation, N/V, euphoria, risk for abuse
Opioid Agonist Interventions
monitor VS/RR (give opioid antagonist if RR too low) monitor during ambulation monitor bowel function hydration, encourage urination lowest dose, short term
Opioid Agonist Admin
get VS before
oral, IM, IV, subcut, rectal, epidural
swallow whole SR
IV slow push 4-5 min
Opioid Agonist Client Instructions
only take PRN
do not drive
get up slow/slow position change
incre fluid, fiber, activity
Opioid Agonist Contraindication/Precau
pregnancy, renal failure, careful admin to old and young
Opioid Agonist Interactions
CNS depressants
anticholinergics (both urine retention)
anti-hypertensives (both incre BP)
Opioid Agonists-Antagonists names
butorphanol and pentazocine (Talwin)
Opioid Agonist-Antagonist Pharm Action
analgesic
mu antagonist, kappa agonist
Opioid Agonists-Antagonists ADR
respiration depression, sedation, dizzy, ligthead, headache, nausea, inre cardiac workload, abstinence syndrome
Opioid Agonists-Antagonists Interventions
ask about opioid use
monitor VS
monitor ambulation
do not give to MI or cardiac insufficiency
Opioid Agonists-Antagonists Admin
IM, IV, intranasal, oral
measure VS
don’t discontinue abruptly
Opioid Agonists-Antagonists Client Instructions
take PRN, short term don't drive caution when changing positions don't take with w/opioid don't use for heart pain
Opioid Agonists-Antagonists Contraindication/Precau
acute MI, cardiac sufficient
opioid dependency
history of drug abuse
Opioid Agonists-Antagonists Interactions
CNS depressants
opioids (decre effects)
Opioid Antagonists name and Pharm Action
naloxone (Narcan)
block opioid receptors
reverse effects of opioids
Opioid Antagonists ADR
ventricular arrhythmias abstinence syndrome HTN vomit tremor
Opioid Antagonists Intervention
monitor BP, VS, heart rhythm
Opioid Antagonists Admin
IM, IV, subcut IV: monitor VS every 5 min effects last 60-90 mins respiratory depression and pain can occur prepare to give every 2-3 mins
Opioid Antagonists Client Instructions
warn them of ADR and pain
Opioid Antagonists Contraindication/Precaut
opioid dependent
respiratory depression not from opioid
caution w/cardiac irritability and seizure
Opioid Antagonists Interactions
decrease opioid effect
Cognition definition
mental action or process of acquiring knowledge and understanding through thought, experience, and the senses
Six domains of cognition
perceptual motor function, language, learning/memory, social cognition, complex attention, executive function
Perceptual motor function
take in outside environment and recognize it, then react
Social cognition
processes, stores, and acts in a social situation
Executive function
self-regulation, being adaptive, higher thinking, flexible
Perception
how you interpret info around you
Memory
ability to retain and recall what you know
Scope of cognition
ranges from intact to impaired
impairment can range from mild, moderate, or severe
Main places in the brain where cognition takes place
cerebrum, diencephalon, brain stem, cerebellum
Optimal brain function depends on
continuous perfusion of oxygenated and nutrient-rich blood
Delirium
sudden, acute, caused by an underlying condition, usually if you can treat the cause it goes away
Cognitive Impairment Not Dementia
will not see a decrease in ADLs/functional ability
Focal cognitive disorders
an example amnesia, can still understand the environment
Intellectual disability
below-average intelligence (IQ score “70),
limitations in conceptual skills, social skills, and ADL
Learning disability
Have average to above average intelligence
Issue with taking in new info
Consequences of cognitive impairment
Increased risk for injury (don’t understand danger) Complicates disease management (may not help w/care)
Decreased ability to care for self and act in social interactions
Financial hardship
Caregiver burden
Risk factors for cognitive impairment
Personal behavior (substance abuse, high-risk activities, injuries)
Environmental exposure
Congenital factors: maternal (substance abuse), birth injuries
Genetic conditions
Health-related conditions: acute/chronic treatments
Assessment for cognitive impairment (history)
can ask pt if you can speak to family/friends
patterns/behaviors history of substance abuse/meds family history how independent pt is brain injuries
Assessment for cognitive impairment (examination)
main points: general appearance, behavior, assess cognitive function
clothes and hygiene, do they pay attention, how they move, bruises from falling, facial expressions and responses, alert and orientated
Mini-Mental State Exam (MMSE)
use to check for cognitive impairment
higher numbers mean they are fine
Aphasia/Dysphasia
language impairment, may have difficulty w/production or comprehension of language
Agraphia/Dysgraphia
inability to write
Agnosia
impaired ability to recognize objects or persons through the five senses
Alexia
impaired reading ability
Apraxia
inability to perform purposeful movements or manipulate objects (even though sensory/motor ability is intact)
Confabulation
making up answers w/o regard to fact
Diagnostic tests for cognitive impairment
Lab tests (ex. WBC, blood glucose, electrolytes) Brain imaging (can ID brain abnormalities) Neuropsychometric testing
Clinical management primary prevention
Promote healthy life
Education on substance abuse, risky activities, healthy pregnancy and aging
Genetic counseling (risk for abnormalities)
Practices to reduce risk for delirium (ex. lose dose/time for meds, have family visit, manage pain and infections)
Collaborative interventions for cognitive impairment (main points)
Treatment depends on cause
Safety measures
Interdisciplinary treatment (work w/medicine, nutritious, speech and language, home health, etc.)
Collaborative interventions for cognitive impairment (general management strategies)
promote general health and comfort reorientation (items from home) pain management regulation of stimulation (ex. lighting, clutter, noise) behavioral management (give activities) sensory aids caregiver support
Pharm for cognitive impairment
treat s/s, diseases, or control behavior
cholinesterase inhibitors and glutamate receptor antagonist
Is dementia a normal part of aging?
No!
Dementia is characterized by
and general adverse effects and risk
decline in one or more of the six domains of cognition
adverse effects on work, ability to perform ADLs
risk for injury, impaired nutrition, social isolation
Dementia etiology
Caused by treatable and untreatable issues (need to treat early)
Most common causes: neurodegenerative or vascular disorders
Dementia onset
Neurologic degeneration is gradual
Vascular dementia may appear abruptly or in a
stepwise progression
Dementia diagnosis
Focused on determining the cause First step: medical, neurologic, and psychosocial history (cognitive/behavior changes, include family, rule out other conditions) Then neuroimaging (rule out other conditions)
Nursing and interprofessional management of dementia
treat risk factors to try to prevent it:
HTN (BV constrict), diabetes (BV damage), smoking (BV constrict), hypercholesterolemia (plaque build up), dysrhythmias (need blood flow & O2)
Alzheimer’s disease (AD) background info
Chronic, progressive, neurodegenerative brain disease
Most common type of Dementia
Cannot be prevented/cured, cannot slow progression
Use only live 4-8 years after diagnosis (but can live longer)
Alzheimer’s disease health disparities
women more likely (live longer)
blacks and hispanics more likely (SES risk, education, lifestyle, CV disease, diabetes)
Alzheimer’s disease etiology
age 65 yr+ (biggest risk factor)
family history
diabetes mellitus (high levels insulin & glucose, insulin resistance, risk to not be able to break down protein)
head trauma
Retrogenesis
Process where degenerative changes occur in
the reverse order in which development
occurred
Behavioral problems w/Alzheimer’s
Repetitiveness; asking same questions Delusions, Hallucinations Agitation, Aggression Altered sleep patterns Wandering Hoarding Resisting care
Neuropsychologic testing tool for Alzheimer’s
Mini-Cog
Mini-mental state examination (MMSE)
Nursing Interventions for Alzheimer’s
Maintain function for as long as possible
Maintain safe environment
Educating/supporting the caregiver(s)
Awareness that hospitalization can worsen disease
Behavioral problems (Redirect, distract and reassure, validate)
Infection prevention
Skin Care
Elimination problems
Sundowning and interventions
Patient becomes more confused and agitated in late
afternoon or evening
Stay calm, maximize daylight, limits naps and caffeine, evaluate meds
Alzheimer’s Disease Safety
Injury: fall, Ingesting dangerous substance, Wandering, Inability to respond to crisis
Minimize risks in home environment
Supervision
GPS
Alzheimer’s Disease Safety
Injury: fall, Ingesting dangerous substance, Wandering, Inability to respond to crisis
Minimize risks in home environment
Supervision
GPS
Alzheimer’s Disease Eating and Swallowing Difficulties
Remind patients to chew/swallow; offer liquids frequently
Provide quiet and unhurried environment
Easy-grip utensils and finger food for self-feeding
Offer liquids frequently
When chewing and swallowing become difficult, use:
Pureed food
Thickening liquids
Nutritional supplements
Orthostatic hypertension
patient moves from a supine to standing position, and there is a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in the HR of 20 beats/min
dizzy, lightheaded
