Objectives for Unit 3

Question 1

Summarize the physiology of comfort

Answer 1

Relief of pain. Pain is the unpleasant sensory and emotional experiences associated with actual or potential tissue damage or described in terms of such damage. Pain is whatever the experiencing person says it is.

Question 2

Examine the relationship between the concepts of comfort & communication, nursing process, and safety

Answer 2

Communication and comfort are important because you and the patient will converse about how their comfort levels are. You will utilize the nursing process to help diagnosis and provide care based on sleep needs. Safety will come into play because you will utilize safe medication practices when helping relieve pain and sleep

Question 3

Describe the pathophysiology, etiology, direct and indirect causes of acute pain

Answer 3

Acute: Nociceptive pain: results from external stimuli on an uninjured, fully functional nervous system. Temporary pain unless underlying cause not treated
Causes: identifiable tissue injury- surgery, inflammation, traumatic injury

Question 4

Describe the pathophysiology, etiology, direct and indirect causes of acute pain

Answer 4

Chronic: Neuropathic pain: caused by nerve malfunction or injuries resulting from trauma, disease, chemicals, infections, & tumors. Consequent spontaneous pain may be due to damage of either peripheral or central nerves. Nociceptive pain often magnified in this type of pain.
Causes: maybe due to cancer or other progressive disorders, tissue injury that is not healing.

Question 5

Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with acute pain.

Answer 5

Pharmacological: opioid analgesics, NSAIDS, nonopioid analgesics
Nonpharmacological: massage, diversional therapoy (music, hobbies, aroma therapy), heat and cold packs

Question 6

Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with chronic pain.

Answer 6

Pharmacological: nonopioid analgesics, antidepressants, NSAIDs, muscle relaxants, opioid analgesics, gabapentin for neuropathic pain
Nonpharmacological: guided imagery, massage, nerve stimulation units, chiropractic interventions, physical therapy, relaxation techniques, positioning.

Question 7

Compare and contrast signs & symptoms for clients with acute pain and clients with chronic pain

Answer 7

Acute Pain: Elevated BP, Increased heart rate, N/V, sweating, rapid/shallow respirations, anxiety, decreased functions in ADLs
Chronic Pain: depression, irritability, impaired mobility/activity, sleep disturbance

Question 8

Identify risk factors & prevention methods associated with symptoms seen at the end of life.

Answer 8

Increased confusion or disorientation, increased periods of sleep, decreased food & liquid intake, changes in respiration (Cheyne-Stokes, apnea), mottling of skin, decreased body temp and BP, loss of bladder & bowel control, changes in muscle control, restlessness.

Question 9

Plan evidence-based care for an individual at the end of life & his or her family in collaboration with other members of the healthcare team.

Answer 9

Palliative Care: Improves the quality of life for patients/families who have life-threatening illnesses by relieving pain and symptom relief, also giving spiritual and psychological support form diagnosis to end of life; may not be actively dying, affirming life and viewing death as normal; if for children then should start with chronic disease at beginning of diagnosis
Hospice Care: Care designed to provide comfort and dignity to patients/families when their illness no longer responds to cure-oriented treatments; doesn’t lengthen life or hasten death, must have been diagnosed with 6 months or less to live; provide emotional, social, & spiritual support for patients/families

Question 10

Demonstrate the nursing process in providing culturally competent care across the life span for individuals with sleep-rest disorders.

Answer 10

Newborns & Infants: 10-16 hours of sleep, place infants on back to sleep
Toddlers: 8-12 hours of sleep + nap, need nap/bedtime routine
Preschoolers: 9-16 hours of sleep, nightmares are common
School-age: 8-12 hours of sleep, need relaxed bedtime routine
Adolescents: 7-10 hours of sleep, complains fatigue r/t not enough sleep
Middle age: total sleep decrease, avoid sleep-inducing meds on reg. basis
Older adults: 7-9 hours of sleep, safe environment, use sedatives w caution

Question 11

Describe the role of the skeletal, muscular, & nervous systems in the physiology of movement.

Answer 11

Skeletal: supports soft tissues, protects crucial components (brain, lungs, heart, and spinal), gives surfaces for attachments (muscles, tendons, and ligaments) provides storage for minerals (calcium and fat), produces blood cells (hematopoiesis)
Muscular: Skeletal: works with tendons & bones to move the body; produces movement by contraction of cells
Cardiac: heart; produces contractions that create the heartbeat
Smooth or visceral: walls of hollow organs (stomach and intestines) blood vessels & other hollow tubes (ureters)
Nervous: Nerve impulses stimulate muscles to contract, Neurons (nerve cells) conduct impulses from one part of body to another
Example: Afferent neurons convey information from receptors in periphery to CNS (person touches hot stove), CNS interprets information (that stove is hot), Efferent neurons send information to muscles & bones, person moves fingers away from hot stove

Question 12

Identify variables that influence body alignment & mobility.

Answer 12

Developmental considerations, Physical health, Mental health, Lifestyle, Attitudes & values, Fatigue & stress, External factors

Question 13

Differentiate isotonic, isometric, & isokinetic exercise.

Answer 13

Isotonic: Muscle shortening & active movement; swimming, ADLs
Isometric: Muscle contraction without shortening; holding a Yoga pose
Isokinetic: Muscle contractions with resistance; lifting weights

Question 14

Assess body alignment, mobility, & activity tolerance, using appropriate interview & assessment skills.

Answer 14

Mobility: General ease of movement, Gait and posture, Morse Fall Risk Scale
Alignment: Joint structure and function, Muscle mass, tone & strength
Activity: Evaluate ability to turn in bed, maintain correct alignment when sitting or standing, ambulate, and perform ADLs. Pay attention to: Vital signs while client at rest, Ability to perform activity, Response during and after activity, Vital signs immediately after activity, Vital signs after clients have rested for 3 minutes
Significant findings: Noticeably increased pulse, respirations, and blood pressure, Shortness of breath, Dyspnea, Weakness, Pallor, Confusion, Vertigo

Question 15

Develop nursing diagnoses that correctly identify mobility problems amenable to nursing interventions.

Answer 15

Activity Intolerance, Impaired Physical Mobility, Risk for Injury

Question 16

Utilize principles of body mechanics when appropriate.

Answer 16

Use proper body position to provide protection from movements, use in ADLs, prevention & correction for posture, enhancement of coordination & endurance, use during activity and rest to prevent injury, used to assess & maintain alignment of clients

Question 17

Use safe client handling & movement techniques & equipment when positioning, moving, lifting, & ambulating clients.

Answer 17

Positioning: use pillows, mattress, and adjustable bed, change position q 2 hours; if client can’t assist- use 2 or more caregivers; if client can move self- lower HOB and push with feet; if client partially can. <200 lbs- 2-3 nurses, if >200 lbs- 3 nurses
Moving: be aware of baseline VS, assess for dizziness & lightheadedness, gait belt
Lifting: use gait belt and proper body mechanics
Ambulating: assess mobility & need for assistance, explain process, assess for dizzy and weakness, make clear path, non-skid footwear, gait belt

Question 18

Describe the pathophysiology, signs & symptoms, and complications of osteoporosis & hip fracture.

Answer 18

Loss of calcium and phosphate from bones, most common metabolic bone disease
Pathophysiology: rate of bone resorption accelerates as the rate of bone formation decelerates, decreased bone mass results and bones become porous and brittle.
Signs & Symptoms: Humped back (kyphosis), Markedly aged appearance, Loss of height of more than 1½″, Muscle spasm, Decreased spinal movement with flexion more limited than extension
Complications: Bone fractures (vertebrae, femoral neck, and distal radius)

Question 19

Describe the effects of osteoporosis and hip fracture on mobility.

Answer 19

It makes bones more vulnerable to fractures as it has decreased bone mass and they become brittle.
Causes: Primary: estrogen deficiency, changes associated with aging; Secondary: underlying disease or agent

Question 20

Discuss the differences between an intermittent & indwelling urinary catheter & the possible need for each.

Answer 20

Intermittent: straight cath; used to drain the bladder for short periods
Indwelling: foley cath; used when catheter is to remain in place for continuous drainage.

Question 21

Discuss possible adverse effects of using an intermittent or indwelling urinary catheter.

Answer 21

Catheter Associated Urinary Tract Infection (CAUTI) or Urinary Tract Infection (UTI

Question 22

Demonstrate proper technique in safe insertion of an indwelling urinary catheter on male & female manikins.

Answer 22

Maintaining sterile field, asepsis technique, hand hygiene

Question 23

Demonstrate proper technique in the removal of an indwelling urinary catheter from male & female manikins.

Answer 23

Must have physician order, remove stat-lock, deflate balloon with syringe, remove catheter, measure urine, and perform peri care.

Question 24

Discuss possible unexpected issues that would prevent the insertion of an intermittent or indwelling urinary catheter

Answer 24

Catheter in vagina, confused patient who keeps moving, urine stops flowing, pain when balloon inflates, urine leaks out of meatus, can’t get past prostate gland

Question 25

Understand the importance of accurately measuring urine output.

Answer 25

Helps with monitoring so that patient does not become dehydrated or fluid-overloaded, CHF, kidney disease, critically ill patients if less than 30 mL/hour

Question 26

Identify conditions in which NG tubes may be required.

Answer 26

Decompress stomach to remove gas and fluid; diagnose GI disorders; administer tube feedings, fluids, and medications; lavage the stomach to remove ingested toxins; intestinal obstruction; when esophagus and stomach need to be bypassed; at risk for aspiration due to gastric reflux

Question 27

Describe the different types of enteral tubes & the purpose for which they are required.

Answer 27

Levin Tube: used to administer feedings and medications
Dobhoff: used to administer feedings and medications
Salem-sump Tubes: useful for irrigating the stomach and drawing out fluid/gas from stomach

Question 28

Demonstrate the proper way to insert an NG tube, determine proper placement, secure, connect to suction & remove an NG tube.

Answer 28

Measure: measure from tip of nose, to the tip of the ear, down to the xiphoid process
Insert: instruct to flex head back toward pillow when first inserted, when pharynx is met then touch chin to chest and sip water to advance the tube down and back as they swallow; stop when breathing; patient may gag and cough but if persists then stop and check placement
Proper placement: attach syringe to end of tub and aspirate gastric contents to place on pH paper; obtain abdominal x-ray (KUB)
Secure: apply skin barrier, use 4in piece of tape with 2in split to nose, then across cheek; secure to gown using tape and safety pin
Suction: hook up to suction using a Christmas tree
Remove: turn off suction, flush with 10mL water or 30-50mL air, clamp tube and remove while they hold their breath

Question 29

Discuss how to safely administer feedings & medications through an enteral tube.

Answer 29

Elevate head of bed, check residual q 4 hours, flush with water before and after, note abdomen with distention or firmness, stop feeding if nauseated or vomits, finger sticks q 6 hours

Question 30

Discuss how to safely administer a large-volume cleansing enema.

Answer 30

Flush tube, gravity works best, use liquid meds, crush tablets, record flush and meds as intake

Question 31

Discuss how to accurately measure intake of tube feedings and medications.

Answer 31

Measure so patient doesn’t become dehydrated or fluid-overloaded, measure in milliliters (mL)