Exam 3--Client safety, mobility, restraints, pressure injuries, pain Flashcards
When to do the fall risk assessment?
Older patients, history of falls, has fallen
what to have prepared and what to do for a patient having a seizure?
–Make sure rescue equipment is at bedside
–stay with client, call for help
measure vitals after
–document precipitating behavior and description
–O2, oral airway, suction, padding for side rails
Ensure rapid intervention with O2, airway, suction
–Saline lock in place for IV access for generalized seizure patients
–Advise caregivers not to put anything in clients mouth, and not to restrain during seizure
–Just lower client to floor or bed, protect head, move nearby furniture, privacy, turn head to side but flexed forward, loosen clothing
what is the most important rule when restraining a patient?
- -use least restrictive possible, shortest duration possible, use as last resort
- -make sure to have a provider order
- -check vitals after, assess
when is it inappropriate to use restraints?
- -Convenience of staff
- -Punishment
- -Clients who are extremely physically/mentally unstable
- -Clients who cannot tolerate the decreased stimulation of a seclusion room
what 4 things should restraints do to not harm patient?
- -Never interfere with treatment
- -Restrict movement as little as is necessary
- -Fit properly and to be discreet as possible
- -Be easy to remove or change
how often to take off restraints and perform mobility?
every 2 hours
- -assess for skin integrity
- -perform hygiene
- -monitor vitals
- -ROM exercises
what does the prescription for restraints include? how does the time differ for adult–kid–less than 9 yr old?
–reason, type of restraints, location paled, how long to use, and type of behavior that warrants
– only 4 hours of restraint for adult, 2 hours for kids 9-17, 1 hour for less than 9
what 9 things do you need to document about restraints?
- -precipitating events/behavior
- -Alternative actions to avoids seclusion or restraints
- -Time of application and removal
- -Type of restraints and location
- -Clients behavior w restraints
- -Type and frequency of care (range of motion, neurologic checks, removal, skin checks)
- -Condition of body part in restraints
- -Clients response at removal of restraints
- -Med administration
What is RACE with fire safety?
rescue
alarm
contain
extinguish
what is PASS with fire safety?
Pull pin
aim
squeeze
sweep
what is body mechanics? what are 2 things that good mechanics do?
–Body mechanics–use of muscles to maintain balance, posture and body alignment
- Body alignment keeps center of gravity stable
- Good mechanics reduces risk of injury
should you avoid repetitive movements when lifting/moving?
yes, avoid
could lead to injury
what is semi fowlers? what is it used for?
Supine, head of bed 15-45 degrees
Prevents regurgitation and aspiration
Good for ppl that can’t swallow well
Promotes lung expansion
what is fowlers? what is it used for?
Supine, head of bed 45-60
During procedures (nasogastric tube insertion/suctioning)
Better chest expansion and ventilation
Better dependent drainage after abd surgery
what is high fowlers? what is it used for?
Supine, bed 60-90
Promotes lung expansion by lowering diaphragm, relieve dyspnea
Helps prevent aspiration during meals
what is supine (dorsal recumbent) and what is it used for?
Lie on back w head and shoulders elevated on pillow, forearms on pillow or at sides
Food support prevents food drop, maintains proper alignment
Ensure vertebrae are straight
what is prone? what is it used for?
Lies flat on abd and chest, head to one side and back in correct alignment
Pillow can be placed under lef, promotes relaxation with knee flexion and dorsiflexion of ankles
Promotes drainage from mouth after throat or oral surgery, inhibits chest expansion
Short term only
what is lateral/side lying position?
Client lies on side with most weight on dependent hip and shoulder and the arms in flexion in front of body
Pillow under head and neck, upper arms, legs and thighs
what is sims’ or semi-prone? what is it used for?
Client on side halfway between lateral and prone
Weight is on anterior ileum, humerus, clavicle; lower arm behind them while upper in front; legs are in flexion but upper leg is flexed at greater angle
Differs from side lying in distribution of weight
Comfortable sleeping position
Promotes oral drainage
what is orthopneic positioning? what is it beneficial for?
Sits at bedside with pillow on overbed table, across lap
Rest arms on overbed table
Allows for chest expansion
Beneficial for COPD
what is trendelenburg? what is it good for?
Entire bed tilted w head of bed lower than foot
For postural drainage and venous return
what is reverse trendelenburg? what is it good for?
Entire bed tilted w foot of bed lower than head
Promotes gastric emptying and prevents esophageal reflux
what is modified trendelenburg? what is it good for?
Lying flat w legs above level of head of bed
Helps prevent and treat hypovolemia and facilitate venous return
what factors affect mobility?
- -Alterations in muscles
- -Posture
- -Injury
- -Impaired CNS
- -Health status and age
- can be temporary, permanent, sudden onset, slow onset
what are the effects of immobility on the integumentary system?
- -Increased pressure on skin, aggravated by metabolic changes
- -Decreased circulation to tissue causing ischemia
what are the effects of immobility on the respiratory system?
- -Decreased oxygenation and CO2 exchange
- -Stasis of secretions
- -Decreased cough response
–nurse should encourage turn and cough every 2 hours
what are the effects of immobility on the cardiovascular system?
–Orthostatic hypotension
–Less fluid volume in circ system
–Diminished autonomic response
–Decreased cardiac output, effectiveness and leads to increased cardiac load
Increased O2 requirement
–Risk of thrombus development
what are the effects of immobility on the metabolic system?
- -Changes in protein, carb, and fat metabolism
- -Decreased appetite
- -Loss of weight
- -Alterations in Ca, fluid and electrolytes
- -Reabsorption of Ca from bones
- -Decreased urinary elimination of Ca, results in hypercalcemia
what are the effects of immobility on the elimination (genitourinary) system?
- -Urinary stasis
- -Change in Ca metabolism with hypercalcemia, leads to renal calculi
- -Decreased fluid intake and increased use of indwelling urinary catheters, resulting in urinary tract infections
what are the effects of immobility on the GI system?
- -Decreased peristalsis
- -Decreased fluid intake
- -Constipation, increasing risk for fecal impaction
what are the effects of immobility on the musculoskeletal system?
- -Decreased endurance, strength, mass
- -Impaired balance
- -Atrophy of muscles
- -Decreased stability
- -Altered calcium metabolism
- -Osteoporosis
- -Pathological fractures
- -Contractures
- -Foot drop
- -Altered joint mobility
–nurse should reposition every 2 hours, perform ROM exercises
what are the effects of immobility on the neurological/psychological system?
- -Altered sensory perception
- -Ineffective coping
- -Emotional status changes–depression
- -Behavioral changes
what does heat vs cold treatment do?
heat: Increases blood flow
Increases tissue metabolism
Relaxes muscles
Eases joint stiffness and pain
cold: Decreases inflammation Prevents swelling Reduces bleeding Reduces fever Diminishes muscle spasms Decreases pain by decreasing the velocity of nerve conduction
what to look for when applying heat/cold treatment?
Redness or pallor pain/burning Numbness Shivering Blisters Decreased sensation Mottling of skin Cyanosis (cold)
–nurse should assess every 5-10 min
what do antiembolic stockings do? how do ROM exercises promote blood flow?
–cause external pressure on muscles of lower extremities to promote blood return to heart
- -ROM cause skeletal muscle contractions, which promote blood return
- -Exercises: (Ankle pumps, Foot circles, Knee flexion)
what is thrombophlebitis (deep vein thrombosis)?
- -Inflammation of vein that results in clot formation
- -Pain edema, warmth, erythema at site
- -Assess bilateral calf and thigh circ
- -Notify provider immediately
- -Position leg elevated
- -Avoid pressure on site of inflamm
- -Anticipate giving anticoagulants
what is a pulmonary embolism?
- -Occlusion of blood flow to one or more of pulm arteries by a clot (usually comes from lower extremities)
- -Shortness of breath, chest pain, hemoptysis (coughing blood), decreased BP, rapid pulse
- -Prepare to give thrombolytics or anticoags
- -Position client in semi fowlers
- -Obtain pulse ox
- -Admin O2
- -Prepare to obtain blood gas analysis
- -Monitor vital signs frequently
what are the 3 stages of wound healing?
- -inflammatory (3-6 days, vasoconstriction, WBCs, Macrophages, fibrin accumulation, clot formation_
- -proliferative (3-24 days, connective tissue/granulation tissue and collagen, wound edges contract, new epi cells)
- -maturation/remodeling stage (day 21, collagen and scar, normal appearance, can take more than 1 year)
what is primary, secondary and tertiary wound healing?
primary intention–edges approximated, surgical incision, low risk for infection
secondary–wound edges widely separated, heal by granulation
tertiary–widely separated, deep, spontaneous opening of previously closed wound (dehiscence), closed later once infection is resolved
what factors affect wound healing?
age, wellness, decreased leukocyte count, infection, anti-inflamm and antineoplastic meds; malnourishment, bad tissue perfusion, low HgB levels, obesity, chronic disease, smoking, wound stress
what are the 5 principles of wound management?
- -Wounds impair skin integrity
- -Inflammation is a localized protective response to injury or destruction of tissue
- -Wounds heal by various processes and in stages
- -Wound infections result from the invasion of pathogenic microorgs
- -Principles of wound care include assessment, cleaning and protection
what does red, yellow, or black wound mean? What should you do for each?
Red = healthy regeneration Yellow = presence of purulent drainage Black = presence of eschar that hinders healing and requires removal
Red–cover
Yellow–clean
Black–debride, remove necrotic tissue
for drainage from a wound, what should you document and look for?
- -Result of healing via inflammatory process
- -Note amount, odor, color, consistency
- -Note integrity of surrounding skin
- -With each cleansing, observe the skin around a drain for irritation and breakdown
- -For accurate measurement of drainage, weigh the dressing
- -Remove sutures and staples
- -Administer analgesics and monitor for effective pain management
- -Admin antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count)
- -Document location and type of wound and incision, status of wound, type of drainage, type of dressing and materials, client teaching, how the client tolerated the procedure
what are different kinds of wound dressings?
–Woven gauze
Absorbs exudate
–Non Adherent material
Does not stick to the wound bed
–Damp to damp 4-inch by 4-inch dressing
Used to mechanically debride a wound until granulation tissue starts to form in the wound bed
Must keep moist at all times to prevent pain and disruption of wound healing
–Self-adhesive, transparent film
Temporary second skin for small superficial wounds
–Hydrocolloid
Occlusive dressing that swells in presence of exudate, composed of gelatin and pectin, forms seal
Maintains granulating wound bed
Leave for 3-5 days
–Hydrogel
Composition is mostly water, gels after contact with exudate, promoting autolytic debridement and cooling
Rehydrates and fills dead space
Might require secondary occlusive dressing
For infected, deep wounds or necrotic tissue
Provides moist wound bed
Not for moderate to heavy draining wounds
Soothing and can reduce wound pain
Prevents skin breakdown (sacrum)
–Alginates
Non adherent dressings that conform to the wounds shape and absorb exudate
Provides a moist wound bed
Packs wounds
Supports debridement
–Collagen
Powders, pastes, granules, sheets, gels
Helps stop bleeding
Promotes healing
what is a wound vac good for?
- -Use of foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing placed for negative pressure (suction) to occur one tubing is connected to unit
- -Speeds up tissue generation
- -Decreases swelling
- -Enhances healing in a moist, protected environment
what are 2 complications of wound healing?
–Dehiscence: Partial or total rupture/separation of a sutured wound, usually with separation of underlying skin layers
–Evisceration: A dehiscence that involves the protrusion of visceral organs through a wound opening
Manifestations
Significant increase in flow of serosanguineous fluid on the wound dressing
Immediate history of sudden straining (coughing, sneezing, vomiting)
Client report of a change or popping, giving way in wound area
Visualization of viscera
when is hemorrhage most probable after injury/surgery?
24-48 hours
what are signs of infection?
Purulent drainage Pain Redness, edema Fever, chills Odor Increased pulse, RR Increased WBC count
what is a pressure injury? What are some manifestations/observations?
pressure injury: Deep tissue pressure injury, persistent nonblanchable deep red, maroon or purple discoloration
- -Discoloration of non intact or intact skin from damage following prolonged or intense pressure or shear
- -Intact skin is nonblanchable with deep red, maroon, purple discolor
- -Open wounds have dark wound bed or blood blister
- -Pain and temp changes can be detected earlier than color changes
- -If subcut or granulation tissue or bone etc is showing, wound should be restaged
what are the 4 (5) stages of a pressure injury?
–Stage 1: Non blanchable erythema of intact skin
Feels warmer or cooler than adjacent tissue
Swollen, can have diff texture than surrounding skin
Treatment
Relieve pressure, turn/reposition freq, use pressure-relieving devices
Keep dry, clean, well nourished, hydrated
–Stage 2: Partial thickness with exposed dermis
Involves epi and dermis
Wound bed is viable with reddish-pink bed without slough, eschar, granulation tissue, adipose tissue
Can appear as intact or ruptured blister
Treatment
Maintain moist healing environment (saline or occlusive dressing)
Hydrocolloid dressing
Nutritional supps
Admin analgesics
–Stage 3: Full thickness skin loss
Visible adipose tissue with poss granulation tissue and epibole (wound edges appear rolled under), some slough and eschar
No exposed underlying tissue
Some undermining or tunnel possible
Treatment
clean/debride wound
Use Prescribed dressing, surgical intervention, proteolytic enzymes
Nutrition supps
Admin analgesics
Admin antimicrobials (topical or systemic)
–Stage 4: Full thickness skin and tissue loss
Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments or tendon exposed in the wound
Epibole, tunneling and undermining common
Treatment
Clean, debride
Use prescribed dressing, surgical intervention, proteolytic enzymes
Perform non adherent dressing changes every 12 hours
Treatment can include skin grafts or specialized therapy (hyperbaric o2)
Nutrition supps
Analgesics
antimicrobials
–unstageable: obscured, full thickness skin and tissue loss
No determination of stage bc eschar or slough obscures the wound bed
Actual depth of injury is unknown unless slough and eschar removed, at which time the wound is restaged
Treatment
Debride until stageable
Do not use alcohol, dakin’s solution, acetic acid, povidone iodine, hydrogen peroxide, or other cytotoxic cleansers on pressure injury wound
what is epibole of a wound? (pressure wounds)
wound edges appear rolled under
what should you do to help wound healing?
–raise heels of bed, monitor for sepsis (LOC, fever, tachycarida, tachypnea, hypotension, increase in WBC, oliguria); reposition every 2 hours, keep head of bed at or below 30 degrees, no wrinkles in sheets, skin hygiene, do not massage bony prominences
what are the 2 types of pain? which is protective, which is not?
acute–protective, temporary, self limiting
chronic–non protective, lasts longer than 6 months
what is idiopathic pain?
pain without a known cause
what is nociceptive pain? what are the 3 kinds?
–Arises from damage or inflammation of tissue
–Triggers pain receptors (nociceptors)
–Throbbing, aching, localized
–Responds to opioids and non-opiods
–Types of noci pain
(Somatic)
Bones, joints, muscles, skin, connective tissues
(Visceral)
Internal organs
Can cause referred pain in other body locations
(Cutaneous)
Skin, subq tissue
what is neuropathic pain? what is allodynia?
- -Arises from abnormal or damaged pain nerves
- -Phantom limb pain, pain below level of spinal cord injury, diabetic neuropathy
- -Intense, shooting, burning, pins and needles
- -Responds to adjuvant meds (antidepressants, antispasmodic agents, skeletal muscle relaxants)
- -Topical meds for peripheral neuropathic pain
- -Allodynia – characteristic feature (stimulus that creates pain that usually wound not be painful)
what is psychogenic pain?
- -More psychological in nature
- -Unable to determine a physical cause for the pain
what are the 4 processess of nociceptive pain?
transduction–conversion of painful stimuli to electrical impulse through peripheral nerve fibers (nociceptors)
transmission– electrical impulse travels along nerve fibers, neurotransmitters regulate it
perception–pain tolerance, pain threshold, physical dependence, addiction
modulation–Occurs in spinal cord, causing muscles to contract reflexively, moving body away from painful stimuli (neuromodulators: endorphins, dynorphin–enkephalins)
what is the gate control theory of pain?
- -Describes the transmission of painful stimuli
- -Recognizes a relation between pain and emotions
- -“Rubbing head after hitting it” makes it feel better
- -Perception of Pain: Pain Threshold
what are 4 substances that cause an inflammatory response, and what are 2 substances that decrease pain transmission and produce analgesia?
inflammation:
- -Substance P
- -Prostaglandins
- -Bradykinin
- -Histamine
analgesia:
- -serotonin
- -endorphins
what are neuromodulators?
- -have an analgesic activity and alter the perception of pain
- -Are endogenous opioid compounds
- -Morphine-like regulators in the spinal cord and brain
- -Produce their analgesic effect by binding to specific opioid receptor sites, blocking the release or production of pain transmitting substances
- -Response can be: Physiologic, Behavioral, Affective
what 7 things should you ask when evaluating pain?
Ask about location
Ask about how it feels
Ask about intensity, strength and severity
Ask about setting (how it affected ADL)
Ask about the timing (onset, duration, frequency)
Ask about associated findings (anxiety, fatigue, nausea, depression etc)
Ask about aggravating and relieving factors
what populations are at risk for under-treatment of pain?
Infants
Children
Older adults
Clients who have substance use disorder
what are some causes of acute and chronic pain?
Trauma Surgery Cancer Arthritis Fibromyalgia Neuropathy Diagnostic or treatment procedures (injection, intubation, radiation)
what factors affect a person’s pain experience?
Age Fatigue Genetic sensitivity Cognitive function Prior experiences Anxiety and fear--increases sensitivity to pain Support systems and coping styles Culture
what are some observations and measurements to make during a pain assessment?
–Facial expressions
–BP, pulse, RR increase with acute pain (vitals will stabilize eventually)
–Hyperalgesia (heightened sense of pain)
–Allodynia
Condition in which client experiences pain during things that are not usually painful (wearing clothes, wind blowing etc)
what are the 3 types of analgesics?
non-opioids: Acetaminophen, NSAIDs, salicylates
opioids: morphine, fentanyl, codeine
adjuvants: Anticonvulsants, Antianxiety agents, Tricyclic antidepressants, Antihistamine, Glucocorticoids, Antiemetics, Bisphosphonates and calcitonin
what should you assess for with a patient on opioids?
–Essential to monitor use and intervene for adverse effects
–Sedation
–Measure LOC and take precaution for resp depression
–Respiratory depression
–Orthostatic hypotension
–Urinary retention
–Monitor for I&O, assess for distension, admin bethanechol, catheterize
nausea/vomiting
–Constipation
–Monitor BMs, fluids, fiber intake, exercise, stool softeners, stimulant laxatives, enemas
what should you be aware of when using a non-opioid and an opioid together?
–opioids have acetaminophen too
beware of hepatotoxic affects of acetaminophen
what are non-pharmacological pain interventions?
- -Cognitive behavioral measures
- -Skin stimulation: Interruption of pain pathways, Cold for inflamm, Heat to increase blood flow
- -Distraction
- -Relaxation
- -Imagery
- -Divert focus
- -Acupuncture, acupressure
- -Reduction to pain stimuli
- -Elevation of edematous extremities (promote venous return, decrease swelling)
what are 3 other pain interventions?
topical, local, and regional anesthesia
what happens if someone has too much of an opioid?
–Sedation, respiratory depression, coma can occur
Identify high risk clients (older, opioid naive)
–Stop opioid and five antagonist naloxone if RR is below 8/min and shallow, or client is difficult to arouse
–Titrate client dose closely while monitoring RR
–Identify cause of sedation
what is breakthrough pain?
- -Pain that breaks through a treatment regimen
- -Another method/drug needs to be used then in addition to current treatment to help
what is ADPIE for pain management?
Assessment
Planning
Diagnosis
Planning/outcome identification
Implementation–understand use of medications, using combination of pain meds and adjuvant therapy
Evaluation, reassess pt to see if intervention was effective
what causes a pressure ulcer?
- -Prolonged tissue ischemia from pressure on capillaries
- -Occur over bony prominences
- -Characterized by inflammation
- -Increased risk for elderly and in paralysis
- -Can happen in 1-2 hours
what are risk factors for decubitus ulcers?
Collagen Loss Decreased subcutaneous tissue Low serum albumin Incontinence Use of cooling blankets Wrinkled linen Altered circulation
what are the 4 sleep cycle stages?
--Stage 1 NREM (Very light sleep Only few minutes Muscle relaxation Loss of awareness and surroundings Vital signs and metabolism decrease Awakens easily Feels relaxed and drowsy) --Stage 2 NREM (Deeper sleep 20 min Vital signs and metabolism continuing to slow Requires slightly more stimulation to awaken Increased relaxation) --Stage 3 NREM (Slow wave sleep or delta sleep Vital signs decreasing More difficult to awaken Psychological rest and restoration Reduced sympathetic activity) --REM (Vivid dreaming 90 min after falling asleep, recurring every 90 min Longer with each sleep cycle 20 min long average Varying vital signs Very difficult to awaken Cognitive restoration)
what are 4 sleep disorders?
Insomnia–acute or chronic
Sleep apnea–central or obstructive
Narcolepsy–sudden attacks
Hypersomnolence disorder–excessive daytime sleepiness
