Test 2 Flashcards
Factors essential to normal functioning of the respiratory system
- integrity of the airway system to transport air to and from lungs
- Properly functioning alveolar system
- properly functioning cardiovascular and hematologic system (blood)
How does the alveolar system work
Oxygenates venous blood
Removes CO2 from blood
How cardiovascular and hematologic system work
Carry nutrients and waste to and from body cells
Thorax
Extends from the base of the neck superiorly to the level of the diaphragm inferiorly
Lungs, diagram portion of the trachea, bronchi
Sternum
Lies in the center of the chest anteriorly
3 parts
3 parts of sternum
Manubrium, the body, xiphoid process
Thoracic cage
12 pairs of ribs
Mediastinum
Central area in the thoracic cavity
Lungs
Two cone shaped, elastic structures
3 lung lobes on right and 2 left b/c of heart
Pleura
Thin, double-layered serous membrane that lines the thoracic cavity
Function of the upper airway
Warm, filter, humidify inspired air
Components of the upper airway
Nose
Pharynx
Larynx
Epiglottis
Epiglottis
Opens and closes helping with stopping unwanted particles
Estacian tubes
Connect upper air way to ears and release pressure
Function of the lower airway
Conduction of air, mucociliary clearance, production of pulmonary surfactant
Components of the lower airway
Trachea
Right and left main stem bronchi
Segmental bronchi
Terminal bronchi
Cilla
Little hairs that act as a filter
Killed by outside factors like smoking
Anatomy of the lungs
Main organ of respiration
Extend from the base of the diaphragm to the apex above the first rib
The right lung has three lobes
The left lung has 2 lobes
The lungs are composed of elastic tissue (alveoli, surfactant, pleura)
Checking the lungs
Front: 2,4,6, and 6 lateral
Back: T1, 4, 7, 10 and lateral 5 and 9
Pulmonary ventilation inspiration
The active phase of ventilation
Involves movement of muscles and the thorax to bring air into the lungs
Pulmonary ventilation expiration
The passive phase of ventilation
Movement of air out of the lungs
Process of ventilation
- the diaphragm contracts and descends, lengthening the thoracic cavity
- the external intercostal muscles contract, lifting the ribs upwards and outwards
- the sternum is pushed forward, enlarging the chest from front to back
- increased lung volume and decreased intrapulmonic pressure allow air to move from an area of greater pressure (outside lung) to lesser pressure (inside lungs)
- the relaxation of these structures results in expiration
Gas exchange
Refers to the intake of oxygen and release of CO2
Made possible by respiration and perfusion
Occurs via diffusion (movement of O2 and CO2 between the air and blood)
Factors influencing diffusion of gases in the lungs
Change in surface area available
Thickening of alveolar-capillary membrane
Partial pressure
Solubility and molecular weight of gas
Transport of respiratory gases
O2 is carried in the body via plasma and RBC
Most O2 is carried by RBCs in the form of oxyhemoglobin
Hemoglobin also carries CO2 in the form of carbohemoglobin
Internal respiration between the circulating blood and tissue cells must occur
Hypoxia
Inadequate amount of O2 available to the cells
Dyspnea
Difficulty breathing
Hypoventilation
Decreased rate or depth of air movement into the lungs
Cardiovascular system
Vital for exchanges of gases
Composed of the heart and the blood vessels
Heart
Cone shaped, muscular pump, divided into four hollow chambers
Upper chambers
The atria receives blood from the veins
Lower chambers
The ventricles force blood out of the heart through the arteries
Gas exchange
The intake of O2 and release of CO2
Made possible by respiration and perfusion
Occurs via diffusion
Factors influencing diffusion of gases in the lungs
Change in surface area available
Thickening of alveolar capillary membrane
Partial pressure
Solubility and molecular weight of gas
Transportation of respiratory gases
O2 is carried in the blood via plasma and RBC
Internal respiration between the circulating blood and tissue cells must occur
How O2 is carried in blood
Most by RBCs in form of oyxhemoglobin
How CO2 is carried in blood
Form of carboxyhemoglobin
Hypoxia
Inadequate amount of O2 available to the cells
Dyspnea
Difficulty breathing
Hypoventilation
Decreased rate or depth of air movement into the lungs
Cardiovascular system
Vital for exchange of gases
Composed of the heart and the blood vessels
Heart
Cone shaped, muscular pump, divided into four hollow chambers
Upper chambers of heart
Arita receive blood from the veins
Lower chambers of heart
Ventricles force blood out of heart through the arteries
Altercations in cardiovascular system
Dysrythmia/arrhythmia
Myocardial ischemia
Angina
Myocardial infarction
Heart failure
Factors affecting cardiopulmonary functioning and oxygenation
Level of health
Developmental considerations
Medication considerations (painkillers)
Lifestyle considerations
Environmental considerations
Psychological health considerations
Respiratory activity in the infant
- Lungs are transformed from fluid filled structures to air filled organs
- the infant’s chest is small, airways are short and aspiration is a potential prob
- res rate is rapid and res activity is primarily abdominal
Synthetic surfactant can be given to infants to reopen alveoli
Crackles heard at end of deep respiration are normal
Respiratory activity in the child
- some subcutaneous fat is deposited on the chest walls making landmarks less prominent
- Eustachian tubes, bronchi, and bronchioles are elongated and less angular
- average # of routine colds and infections decreases until child enter daycare/school
- good hand hygiene and tissue encouraged
- by end of late childhood immune system protects from most infections
Prevalent diseases in children
RSV, Croop, ear infections
Proven coordination with smoking parents
Respiratory functioning in the older adult
- bony landmarks are more prominent die to loss of subcutaneous fat
- kyphosis contributes to appearance of leaning forward (contributes to lungs bc of compressing)
- barrel chest deformity may result in ^ anteroposterior diameter
- tissues and airways become more ridged; diaphragm moves less efficiently
- ^ risk for disease, especially pneumonia
Physiological changes with age respitory
- decreased in stretching and compliance of chest wall
- decrease rib mobility and tone
- decrease in strength and function of resp muscles
- decrease depth and oxygenation
- decreased ability to cough
-** ^ risk for accumulation do secretions = pneumonia
Guidelines for obtaining a nursing history
- determine why need care
Determine kind of care to mailing a sufficient intake of air - identify current/potential health deviations
- identify actions performed for meeting respiratory needs
- make use of aids to improve air intake and effects on lifestyle and relationships
Cardiac coronary catherization
Measures heart
Assess cardiopulmonary function
Cardiac exercise stress test
Testing heart using meds or exercise
Assess cardiopulmonary function
Echocardiogram
Measures heart
Assess cardiopulmonary function
Endoscopic studies
Broncoscopy, someone w/ reflux or aspiration
Assess cardiopulmonary function
Holter monitor
Heart test
Assess cardiopulmonary function
Lung scan
Simple test
Assess cardiopulmonary function
Skin tests
TB or allergy
Assess cardiopulmonary function
Radiography
X-ray of chest
Assess cardiopulmonary function
ABGs
Arterial blood graphs
Measurement of arterial oxygenation and CO2 levels
Used to assess adequacy of alveolar ventilation and the ability of the lungs to provide O2 and remove CO2
Also assess accident base balance
Sputum Collection and Analysis
Culture and sensitivity, cytology
Boogers/phlem
Best results in morning
Pulmonary function tests
Measure inspiration and expiration rates and ratios
Other diagnostic procedures and tests
Chest X-rat, CT, MRI, O2 sat
Nursing interventions promoting adequate respiratory function
Teaching about pollution free environment
Promoting:
- optical function
- comfort
- proper breathing
- coughing (and controlling)
Managing chest tubes
Suctioning airways
Meeting oxygenation needs with meds
Promoting proper breathing
Deep breathing
Using incentive spirometry (at least 10x an hour)
Pursed lips breathing
Diaphragmatic breathing (extra deep)
Managing chest tubes
-assist with insertion and removal
- monitor the patient’s respiratory status and vital signs
- Check dressing
- Maintain latency and integrity of drainage site
Promoting respiratory comfort
Positioning
Maintaining adequate fluid intake
Providing humidified air
Performing chest physiotherapy
Bronchodialtors
Open narrowed airways
Nebulizers
Disperse fine particles of liquid medication into the deeper passages of the respiratory tract
Meter-dose inhalers
Deliver a controlled dose of meds with each compression of canister
Dry powder inhalers
Breath-activity delivery on medication
Oxygen delivery systems
Nasal cannula
Nasopharyngeal catheter
Transtracheal catheter
Simple mask
Partial rebreather mask
Nonrebreather mask
Venturi mask
Tent
Precautions for O2 admin
Avoid open flames
No smoking sign (nicotine patches if needed)
Check electrical equipment in room is in good working order
Avoid wearing and using synthetic fabrics
Avoid using oils in area
Anterior chest landmarks
Midsternal lines
Midclavicular lines
Anterior axillary lines
Posterior chest landmarks
Seventh cervical vertebra
T1 4 7 10
Veterbral line
Scapular lines
Posterior axillary lines
Vesicular sounds
Low pitched, soft sound during expiration heard mostly over the lungs
Longer inhale shorter exhale
Bronchial
High pitched and longer, heard primarily over trachea
Longer exhale shorter inhale
Bronchovesiclar
Medium pitch and sound during expiration, heard over the upper anterior chest and intercostal are
Equal inspiration and expiration
Crackles
Intermittent sounds occurring when air moves through airways that contain fluid
Heard at end of inspiration
All not cleared by coughing
Classified as fine, medium or coarse
Wheezes
Continuos sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions or tubes
Classified as sibilant or sonorous
Pleural friction rub
Dry rubbing, grating inflammation of pleural surfaces loudest lateral anterior surface
Stridor
High pitched whistling or gasping with harsh sound quality
Seen in airway obstruction
Esophagus
Peristalsis
Stomach
Mixes food with enzymes to continue the process of digestion
Pancreas
Secretes digestive enzymes into the duodenum to break down proteins, fats, and carbohydrates
Behind the liver (mid-epigastric region)
Liver
Processes absorbed nutrients from the small intestine, produces bile secreted into the small intestine to help digest fats, detoxifies
Gallbladder
Stores and concentrates bile
within the liver connected to the small intestine
Parts of the small intestine
Duodenum: breaks down nutrients
Jejunum: absorbs nutrients
Ileum: absorption of neutrients
Physiology of the small intestine
22 foot long muscular to be
Breaks down food with the help from pancreas and liver
Peristalsis
Moves food alone
Contents of the small intestine
Semi solid to liquid
where does B12 absorb
The ileum
Appendix
Job is to “reboot” the digestive system with bacteria safely harbored in it
Located just below the normal one-way flow of food and bacteria in the large intestine
Anatomy of the large intestine
6 foot long muscular tube
Cecum
Ascending (right) colon
Transverse (across) colon
Descending (left) colon
Sigmoid colon (storage)
Rectum
Job of large intestine
Absorbs water, forms stool
Stool
Mostly food debris and bacteria
Bacteria: synthesize vitamins, process waste products and food particles, and protects against harmful bacteria
Rectum
8 inch chamber that connects colon to the anus
Where gas or stool enters the rectum, neurological sensors message the brain
The brain then decided - empty or not - if not sensation temp goes away
Infants and children abdominal (not just pot belly)
First stool is meconium
Liver takes up more space than adults
Abdominal wall thinner
Organs palpable
Bladder located higher than adults
Pregnant women abdominal
Morning sickness 50-70%
Heartburn
Constipation
Hemorrhoids
Bowel sounds diminished
Appendix displaced up and right
Hospice/end of life abdominal
Pain meds are constipating
Disease process might cause diarrhea or constipation
Limited oral intake
Incontinuence (muscles around anus lost -> just comes out)
Circulation shunting to vital organs
Visceral pain
Organ
Dull, diffuse pain
Parietal pain
Lining
Sharp pain
Referred pain
Pain felt in area away from source
Hernias
Epigastric
Umbilical
Incisional
Inguinal
Femoral
RUQ contains
Gallbladder
Liver
Duodenum
Head of pancreas
Right adrenal gland
Portion of R kidney
Some of ascending/transverse colon
Pain in RUQ indicts
Cardio: MI, angina
Pulmonary: pneumonia
GF: cholecystitis, cholelithiasis
Hepatic: hepatitis, C , A
Intestine: duodenal ulcer, appendicitis
LUQ contains
Spleen
Left lope of liver
Stomach
Pancreas body
Left adrenal glad
Portion of left kidney
Potion of the transverse/descending colon
Pain in LUQ
Cardio: MI, angina
Pulmonary: PE, pneumonia
Spleen: ruptured
Stomach: GERD, gastric ulcer,hiatal hernia
RLQ contains
Ovaries
Right spermatic cord
Ascending colon
Lower part of the adrenal
Portion of right kidney
Right ureter
Appendix
Pain in RLQ
Ovary/uterus: ectopic preg, ovarian cyst, pelvic
Inflammatory disease
Intestines: perforation, constipation, diverticulitis
Hernia
Kidney: nephrolithiasis, infection
LLQ contains
Ovaries
Left spermatic cord
Descending colon
Lower part of adrenal
Potion of left kidney
Left ureter
Pain in LLQ
Ovary/uterus: ectopic preg, ovarian cyst, pelvic
Inflammatory disease
Intestines: perforation, constipation, diverticulitis
Hernia
Kidney: nephrolithiasis, infection
Pain in shoulder (referred pain)
Ruptured spleen, ectopic preg, pancreatitis, perforated duodenal ulcer
Scapular pain (referred)
Cholecystitis, MI, angina, pancreatitis
Pain in thighs, genitals (referred)
Renal
Pain in lower back (referred)
Pancreatitis, rectal lesion, abdominal aortic aneurysm
Umbilical are (referred)
Small intestine, appendix, colon
Positive murphys sign
Cholecystitis
Blumberg’s sign
Rebound tenderness
Obturator test
Appendicitis
McBurney’s sign
Press on RLQ with release of hand = pain =
Appendicitis
Obturator test
Appendicitis
Holds client’s right ankle in their right hand
Use left hand, the examiner rotates the hip by moving the right knee to and away from body
This is flexion and internal rotation of the hip
Pain in RLQ could indicate appendicitis
Special considerations with infant./children abdomen
Contour is protuberant “pot belly”
Umbilical hernia
Special considerations of pregnant women’s abdomen
Protuberant
Constipation common
Sounds are different
Special considerations elderly abdomen
Increased abdominal fat
Less musculature
Organs may be easier to palpate
…oscopy
Visualization with lighted instrument
Esophag…
Gastr…
Colon…
Sigmoid…
Biopsy mucous and lesions
Remove lesions
Cauterize bleeding
Colonoscopy
Examines the entire length of the colon
Sigmoidoscopy
Examines lower third of the colon
Contrast medium studies
Use barium
Barium swallow
Esophagus
Upper gastrointestinal
Barium enema
Esophagus, stomach, small intestine
Barium Enema
Barium
Like cement
Can cause constipation and blockages
Need lots of fluids and movement after
Turns stool white
Occult Blood test
Large intestine
Checks for blood in stool
Must avoid red meat, raw fruits and veggies, aspirin, vitamin C for up to 3 days before
May cause false +/-
Occult Blood test
Large intestine
Checks for blood in stool
Must avoid red meat, raw fruits and veggies, aspirin, vitamin C for up to 3 days before
May cause false +/-
NPO
Non per Orum
Nothing by mouth
If client is well nourished, can tolerate for short time
Consider health he: diabetes hypoglycemia
When NPO is used
Prior to surgeries, GI abnormalities, N&V, L&D, prior to some lab work or tests & when comatose
NPO keep in mind
Keeping mouth moist
Good oral care
Irritable due to lack of intake
Clear Liquid
Considered any liquid you can see through at room temp
Broth, coffee, carbonated bevs, ice pops, gelatin, clear juices, tea usually written as “clear diet,advance as tolerable”
Long term would require IV nutritional sub
When clear liquid diet is used
1st step after surgery
Allows nurse to assess tolerance to PO intake
Clear Liquid look outs
Watch for N/V, full feeling , diarrhea, abdominal pain and distinction
Want client to feel hungry, have +BS, passing flats, able to eat 1/2-3/4 tray before advancing
Full Liquid
Includes all of clear diet contents plus
Milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, veggie juices, milk and egg substitutes
Better nutrition can go a few days with out other supplementation
Soft diet
Regular diets that are modified to remove foods that are more difficult to digest and chew
- no high fiber (salads,roughage)
- no high fat
- no highly seasoned
AKA: bland diet or low fiber diet
nutritional satisfactory
Problems with soft diet
Constipation
Puréed diet
Foods are blended to liquid form - meat veggies etc
Foods are blended with broths, gravy, cream soups, cheese, milk, tomato juice and fruit juice to increase calorie/nutritional value
Uses of purred diet
Clients with difficulty chewing/swallowing and facial/oral surgery
Problems with puréed diet
Refusal by patient
Mechanical soft diet
Foods are modified for texture
Chopped,ground or puréed
Masked soft ripped fruits
Cooked mashed soft veggies
Uses of mechanical soft diet
Patients with difficulty chewing, surgery to head, neck, mouth
Regular (or house) diet
Anything goes
Patient can generally order what they want depending on health care facility’s dietary system
Problems with regular diet
Patient might not like the food provided and will want to bring in their own
NAS
no added salt or sodium restricted
Uses of NAS
Clients with heart disease, hypertension, kidney disease, ascites
Intake measurements
By mouth
IV fluids/TPN/PPN
Antibiotics
External feedings
Flushes
Output measurements
Urine
Stool
Drains
Sweat (rare)
Wound drainage (rare)
Challenges in nutrition
Impaired appetite
Eating alone
Culture
Religion
Serving times
State of health
Oral cavity
Restrictions
Thrush
White coating on tongue
Thrush
White coating on tongue
Enteral feeding
Feeding administered directly into the stomach
Oral gastric or nasogastric
PEG tube percutaneous gastrostomy or jejunostomy tube
Nasogastric tube
Enteral feeding
Inserted through nose and down into stomach
Short term (<6 weeks)
Risk for aspirating the tube feeding solution into the lungs
Aspiration looks like
Sudden increase in HR, RR, anxiety, auscultate rhonchi, committing solution, decreased O2 sat
Avoid by having client sit in 30 degree or higher or right side if comatose when tube feeding is running and for one hour after
Points to consider for nasogastric tube
Room temp
Assess residuals prior to feeding and evaluate absorption
Residuals < 100-150cc it’s okay to administer, >150 hold feeding
Check for placement with x-ray
Assess bowel sounds prior and hold feeding and notifying if absent
Look for signs of dumping syndrome
Flush tube with water
Intermittent enteral feeding
300-500 ml administered several times a day
Preferred method
Bolus intermittent enteral feeding
Bag hanging by gravity to a syringe is used to relieve the formula into the stomach
Quick delivery may not be tolerated
Continuous feedings enteral feedings
An infusion pump administered feedings in constant flow 24 hours a day
Stomach never gets a rest
Keep patient up at 30 degrees at all times
Cyclic feedings enteral feedings
Continuous feedings relieved over less than 24 hours (usually at night)
Parenteral feedings
Relievers nutrients directly into the bloodstream, bypassing the GI tract
Duration for treatment is generally < 14 days
Solutions in parenteral feeding
Dextrose, amino acids, electrolytes, vitamins, and trace elements in sterile water
Uses of parenteral feedings
When clients can not meet nutritional needs orally or enterally
Comatose, non functioning GI tracts, extensive burns, extensive surgery, extensive cancer treatments, premature infants
TPN
Total parenteral nutrition
Highly concentrated, hypertonic nutrient solution
Prefer a central IV line, peripheral line increases risk of infection and phlebitis
TPN and neonates
Most commonly administered through a peripheral IV, sometimes central like
PPN
Peripheral parenteral nutrition
Not as nutrient sense as TPN
Less caustic to the veins
Complications of parenteral nutrition
Liver damage
Hyperglycemia
Sepsis
Phlebitis/infiltration
Complications of central line placement (infection, catheter fracture, clotting)
Bowel eliminations
Frequency varies from person to person not everyone has daily
Assessment of bowel eliminations
Color: concern is for blood in the stool
Odor: c-diff distinct
Amount: small, medium or large
Consistency: watery, soft, hard
Frequency: how often
Bristol stool chart
Type 1: sever constipation
Type 2: mild constipation
Type 3: normal
Type 4: normal
Type 5: lacking fiber
Type 6: mild diarrhea
Type 7: severe diarrhea
Anesthesia and bowel function
Slows normal colonic movement
Ileus
Pathological factors and bowel function
Spinal cord injury
Cancers
Pain and bowel function
Discomfort when defecating
Constipation
Medication and bowel function
May increase or decrease GI motility
May affect appearance
Laxative
Ostomy
Term for a surgically formed opening from the inside of an organ to the outside of the body
Fecal ostomies
Intestinal mucosa is brought to the abdominal wall and a stomach is formed by suturing the muscle to the skin
Ileostomy
Bowel stoma
allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma
Colostomy
Bowel stoma
Permits formed feces in the colon to exit through the stoma
Why use colostomy
Bowel blocked or perforated
Cancer
Trauma
Diversion for wound management
Inflammatory bowel disease exacerbation
Temporary colostomy
Used if allowing bowel to heal
Permanent colostomy
Rectal cancer or portion removed, ulcerative colitis, Chrohn’s
Stoma assessment
Healthy stomach is red or pink and moist
Bleeding should be minimal
Stomach fresh post op is swollen
Note size - stabilizes in 6-8 weeks
Most protrude 1/2-1 inch
Keep peristomal skin intake and healthy
Pale stoma
Anemia or nutritional deficits
Pale stoma
Anemia or nutritional deciliters
Dark purple/blue stoma
Ischemia or compromised circulation
Brown stoma
Slough from diseased bowel
Black stoma
Tissue death
Ostomy nursing interventions
Change pouch/clean stoma when due or leaking
Keep skin around clean and dry
Measure I and O ***
Educate
Encourage to participate in care
Name your Ostomy
Enemas
For constipation management or to administer meds
Introduction of a solution into the rectum and large intestine
When using for treatment the solution is given to treat area directly ask to hold as long as possible
Enemas
For constipation management or to administer meds
Introduction of a solution into the rectum and large intestine
When using for treatment the solution is given to treat area directly ask to hold as long as possible
How enemas work
Act by distending the intestine and sometimes irritating the intestinal mucosa thereby increasing peristalsis expulsion of feces and flatus
How enemas work
Act by distending the intestine and sometimes irritating the intestinal mucosa thereby increasing peristalsis expulsion of feces and flatus
Purpose of enemas
Relieve constipation or fecal impaction
Promote visualization of intestinal tract during x ray
Recent escape of feces during surgery
Treatment for infections
Types of enemas
Cleansing enema
Retention
Carminative - relieves gas
Return-flow
Enema administration
Position on left side (sim) so fluid flows down to sigmoid on left side
Raise the solution to increased the force of flow if applicable
Admin fluid slowly
If pain or cramping clamp tube for 30 sec and restart at slower rate
Instruct client to hold for 10-15 minutes or as long as possibly
Document intervention and results
Promoting bowel elimination
Promote regular defecation
Provide privacy
Schedule
Lots of fluid and fiber
Provide as normal position as possible with bedpan
Pain
Unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage or both
Pain is whatever the experiencing person says it is, existing whenever he says it does
Pain process
Transduction
Transmission
Perception of pain
Modulation
Transduction
Activation of pain receptors
Transmission
Coduction along pathways
A-deltas and C fibers
Perception of pain
Awareness of the characteristics of pain
Modulation
Inhibition or modification of pain
Gate control theory of pain
Small and large diameter never fibers conduct and inhibit pain stimuli towards the brain
Gating mechanism determines the impulses that reach the brain
**putting counter pressure on the are in pain can decrease the pain
Gate control theory describes
The transmission of painful stimuli and recognizes a relationship between pain and emotions
Acute pain
Rapid onset, lasts less than 6 months
Caries in intensity and duration
Protective in nature
Chronic pain
Maybe limited, intermittent or persistent
Last longer than 6 months
Last beyond the normal healing time period
Periods of remission or exacerbation are common
Psychological pain
Emotional or mental pain
Psychosomatic or psychogenic pain
Psychological pain becomes physical
Nociceptive pain
Nerve receptors detecting harmful stimuli
Neuropathic pain
Damage or dysfunction of any level of nervous system
Inflammatory pain
Two aspects - inflammatory and immune responses accompanying and causing both nociceptive and neurogenic pain and inflammatory pain syndromes
Somatic pain
Stimuli in tissues activates nerve receptors and produces sensation of pain
Visceral pain
Nerves in internal organs are stimulated
Radicular pain
Generated by stimuli at nerve root at connect to spinal nerves
Phantom pain
Pain in part of body that has been removed
Cancer pain
Little to no pain, a true, chronic, nerve, bone, tissue, referred, phantom, inflammatory
Cutaneous pain
Pain that originates from skin, muscle or peripheral nerves
Pain from shot
Cutaneous pain
Pain that originates from skin, muscle or peripheral nerves
Pain from shot
Referred pain
Sensation of pain distant from actual source
Heart attack
Terms describing pain
Quality: sharp, dull, diffuse, shifting
Severity: severe or excruciating, moderate, slight/mild
Periodicity: continuous, intermittent, brief or transient
General assessment of pain
Verbalization and description
Onset and duration
Etiology or mechanism
Location
Quality, character and intensity
Aggravating or causal factors
Alleviating or causal factors
Effect on function
Pain management goal
basic methods of assessing pain
Self reply
Identify pathologic conditions or procedures that could cause
Consider physiologic measure (BP pulse)
Report of family member or caregiver
Nonverbal behaviors
Protecting painful area
Attempt an analgesic trial and monitor results
PAINAD
Pain assessment in advances dementia scare
Observe and score on breathing, negative vocalization, facial expression, body language, consolability
NRS
Numberic rating scale
1-10
Wong-Baker FACES
Pain scape based on facial expression
Usually 6 faces
NIPS
Neonatal infant pain scale
Behavioral tool
Facial expression, breathing, crying, motor activity, state of arousal
Diagnosing pain
Type
Etiologic factors
Behavior, physiological, affective response
Other factors affecting pain process
Nursing intervention for pain
Trusting relationship
Manipulating factors affecting pain experience
Initiating complementary health approaches and integrative health care
Managing pharmacological relief
Ensuring ethical and legal responsibility to relieve
Understanding placebo controversy
Cutaneous stimulation
Alternative way to relief pain
Holding hand and rubbing it
Analgesic administration
Opioid
Adjuvant
Non-opioid
Principals of analgesic admin
Ongoing assessment
Management of breakthrough pain
Concern about prescription analgesic abuse
Numeric Sedation Scale
S: sleep, easy to arouse, no action necessary
1: awake and alert, no action necessary
2: occasionally drowsy, but easy to arouse, no action necessary
3: frequently drowsy, drifts off to sleep during conversation, reduce dosage
4: somnolent with minimal or no response to stimuli, discontinue opioid, consider use of naloxone (narcan)
Pain management regimens for cancer or chronic pain
Give meds orally if possible
Admin meds ATC (around the clock) rather than PRN (as needed)
Adjunct the dose to achieve maximum benefit with minimum side effects
Allow patient as much control as possible over the regimen
Pain treatment in children
No aspirin under 18
<4000 mg of Tylenol in 24 hrs
Pain treatment in older adults
Communication difficulties
Denial of pain
Metabolism rate is lower so it takes longer to begin working and to leave their system
Methods for admin of analgesics
Patient controlled analgesia (PCA)
Epidurals analgesia and peripheral nerve blocks
Topical anesthesia
Ageism
Discrimination based on age
The three Ds
Dementia
Delirium
Depression
Dementia
Progressive, chronic decrease in cognitive function
Characterized: slow, progressive onset, memory loss, confusion, difficulty solving problems, long term, permanent
Delirium
Acute, often sudden disturbance in mental status that can lead to confusion, disorientation and difficulty focusing
Characterized: fluctuates, temporary and reversible
UTI? Could cause if resolve goes away
Depression
Mood disorder marked by persistent feeling of sadness, hopelessness and lack of motivation
Characterized: gradual or sudden, often treatable with therapy and meds
Gerontology
Scientific study of aging
Gerotranscendence
Psychosocial theory erkison and Maslow
Shift of perspective with age -> increase life satisfaction and more cosmic/ spiritual understanding of life
Polypharmacy
Lots of meds for one person
Sacropenia
Wasting of the muscle, trouble walking, falling a lot
Sacropenia
Wasting of the muscle, trouble walking, falling a lot
Sundowning
Alert and oriented during the day but as it goes on gets increasingly more confused and disoriented
Gerontological
Related to field of gerontology including study, research and application of knowledge of the aging adult
Sandwich generation
Usually between ages of 40-50
Trying to take care of their family and also their aging parents
Biological and psychological theories of aging
Maslow and Erkison
Combination of the two neither is 100% right
Also effected by genetics life experiences and choices
Roles of the nurse
Promote health
Prevent illness
Promote independence
Promote gerotranscendence
Nursing assessment
Physical
Psychological
Emotional
History
Medication reconciliation
Changes in body contour in older adults
Bony prominence show
Weight distributed (to waist and hips)
Subcutaneous tissue leaves the face and arms and moves to abdomen/hips
Height decreases
Musculoskeletal changes in older adults
Wide base gait
Weight decreased (sacrcopeia)
Lead to decreased: physical endurance, physical activity, loss of activity
Older adult composition
Decrease in total body water
- due to the decrease in muscle cell mass
Unintentional weight loss NOT part of aging
- older adults experience early satiety - feeling of being full-change in gastric hormone
Older adult temp regulation
Less likely to have a fever
Less fat reserves
More likely to have hypothermia
Slower metabolism - the capacity for endotherms to regulate temp declines
Produce less body hear
Thermoregulatory impairment
Median temp 96.8
Swear glads diminish in size and function
Causes of hypothermia
Decrease activity
Severe hypothyroidism
Hypoglycemia
Malnutrition
Acute illness (preserve organs)
Medications
Meds that can cause hypothermia
Beta blockers neuroleptics and anesthetic
Meds that can cause hypothermia
Beta blockers neuroleptics and esthetics
Epidermis older adults
Regeneration slows
Reduced barrier protection
Dermis older adults
A supportive layer a 20% loss causes older skin to look more transparent and frail
hypodermis older adults
Contains connective tissues, blood vessels and less adipose tissue
Dry skin (xerosis) and accompanied by itchy skin (pruitus)
Hair older adults
Loss melanin (color)
Alopecia may occur
Hair older adults
Loss melanin (color)
Alopecia may occur
Nails older adults
Thicken (onychorrhexis)
Brittle, flat
Vertical ridges
Onycholysis (nails separating from nail bed)
Head and neck older adults
Bones are more prevalent
Great vessels may have bruits (atherosclerosis)
Neck shortens r/t osteoporotic changes
Thyroid usually not palpable
Loss of subcutaneous tissue
Eyes older adults
Decreased eyelid elasticity
- ectropion, entropion
Conjunctiva become thinner and yellow with increased risk to infection
Pingucula
- overgrowth of conjunctiva
Lacrimal glands and ducks (blocked)
Tears decrease
Physiologic changes in eyes
Eyeballs sit deeper in sockets
Cornea flattens and iris fades
Pupils become smaller, scleras become thick and ridged
Presbyopia
Decreased ability to adjust near/far vision
Vision impairments with age
Decreased visual acuity (especially near)
Narrowing of visual field
Difficulty gazing upward and maintaining convergence, adapting to light changes
Glaucoma
Black faded right around field of view
Cataract
Blurred vision
Factors affecting hearing
Cerumen build up
Corgi (hearing receptor) and the auditory nerve atrophy
Tympanic membrane thickening
Tinnitus
Presbycusis
Hearing loss
Hearing impairment
Decreased tine discrimination
Decreased ability to discern constants ( L, M, N,P)
Decreased equilibrium due to vestibular changes
Signs and symptoms of hearing loss
Increased TV volume
Tilting head towards person speaking
Cupping hard around ear
Watching lips
Speaking loudly
Not responding
Smell perception and Agee
Declines after age 60
Rapid decline at age 80
Cell loss
- olfactory bulb
- sensory cells
Decrease in appetite and smell
Mouth and teeth and age
Teeth loose enamel and dentin
- become more vulnerable to tooth decay
- incident of periodontal disease
Dentures
Taste perception and age
Decrease taste gradually decline
- taste buds atrophy
- amylase decreased in saliva-enzyme aids in digestion
- accelerated by meds or smoking
- Decreases appetite
Musculoskeletal structure age
Discs become thin-lose height
Posture adjustment
Bones and age
Decrease in bone density
Joints, tendons, and ligaments and age
Cartilage changes
Tendons mat shorten- contractures
Muscles and age
Atrophy of muscle tissue - weakness
Heart and age
Valves - calcification may produce murmurs
Conductivity - SA node, pacemaker of the heart
Blood vessels and age
Arteries - atherosclerosis = PVD (caused by build up of plaque in arterial walls)
Veins - insufficiency = poor venous return
Other cardiovascular changes with age
Atrial Fibrillation can occur from fibrosis or SA node blood clots
More likely to show s/s of cardiovascular changes r/t dependent postitions
Respiratory system and age
Limited chest expansion
Senile emphysema - increase in size of alveolar
Alveolar Duct Ectasia - widens/thickens
Loss of elastic recoil deep breaths
Stiffening of chest wall - COPD
Retaining CO2
Less responsive cilia
Diminished cough
Less mobility
Kidneys and age
Loss of nephrons
Decreased kidney mass
Renal vessels and age
Decreased renal blood flow
Ureters bladder urethra and age
Decreased tone and elasticity
Decreased bladder holding capsity
Urgency and frequency increase
Nocturia
Glomerular Filtration Rate
Rate the kidneys are filitering
Linear decline with age
Thyroid gland and age
Incidence of hypothyroidism
Usually requires lower doses of thyroid replacement
Parathyroid gland and age
Changes in it may be cause of alteration in calcium
Due to bone loss
Pancreas and age
Secretion does NOT decrease
Tissue may level decrease sensitivity to insulin
Esophagus and age
Contraction increases
Propulsion is decreased
Stomach and age
Decreased motility
Increase risk for aspiration
Reduction secretion of bicarbonate and gastric mucous
CNS and age
Neurons shrink
Neurotransmitters - dopamine/serotonin declines 10% per decade
PNS
Motor sensory and reflex’s decrease
Female reproductive system and age
Decreased estradiol
Breast size decreased
Breast lumps more evident
Post-menopause
Cessation menses, atrophy of ovaries
Female reproductive system and age
Decreased estradiol
Breast size decreased
Breast lumps more evident
Post-menopause
Cessation menses, atrophy of ovaries
Male reproductive system and age
BPH (benign prostatic hypertrophy)
- dripping/difficulty initiating urine stream
May see an increase in breast fatty tissue
Immune system and age
Decrease in T-cell function
Decrease in response to foreign antigen
- flu shot
Sleep and age
Interrupted REM episodes
Increased total daily sleep - naps
Increased awakening after sleep onset
- wake up feeling tired
Mood and behavior and age
Depression
Anxiety
Irritability
Fear
Despair
Risk for suicide
