055T Exam 2 Study

Nursing Assessments for Acute Pain

Nursing Assessments for Acute Pain

• Classified as ≤6 months

• ID where pain is stemming from

• OLDCART

Nursing Interventions for Acute Pain

• Med administration, reassess w/ pain scale 30 MINS after

  • Numerical Pain Scale or Wong-baker faces

Therapeutic Communication Example for Acute Pain

• “I’m going to give you medication to help you feel comfortable”

Non-Pharmacological Communication for Acute Pain

• Tells patient to take deep breaths

  • Distracts pt momentarily

Nursing goal for Acute Pain patients

• Pain management

  • Short or long-term (SMART GOALS)

    • Pain will be decreased to 3 by xx/xx/xxxx date

    • Promoting ADLs

Type of patients to use Wong Baker Faces

• Aphasia (language disorder)

• Cognitive impaired

  • Dementia

  • Alzheimers

• Patients who cannot speak out loud

  • Ex. Patients on ventilator

• Children

Types of patients who suffer from Acute Pain

• Cancer

• Chronic

• Abdominal pain

• Trauma

Nursing Interventions for Insomnia

• Medications

  • Ativan

• Relaxation techniques

  • Meditation

• Promote bedtime routine/rituals

  • Drinking warm milk

• Cluster care

  • Avoid disrupting sleep

• Reduce environmental stimuli

  • No phones

Nursing Interventions for Ineffective Airway Clearance

• Suctioning

• Encourage coughing + deep breathing exercises

• Bronchodilators

• Monitor O2 sat

• Incentive spirometry

• CPT

Nursing Goal for Ineffective Airway Clearance

• To reduce secretions in patient airway

Nursing interventions for Impaired Gas Exchange patients

• Monitor O2 levels

• Administer Bronchodilator

• Supplemental O2

• Incentive Spirometers

• Expectorants

  • To spit out sputum

• Decongestants

Nursing goal for Impaired Gas Exchange patients

• Patient coughs out secretions with ease

Impaired Spontaneous Ventilation definition

• Inability for patient to breathe independently

  • Can cause muscular atrophy as diaphragm and intercostal muscles are not being used

• Weakened respiratory muscles

• Neurological issues

Nursing interventions for Impaired Spontaneous Ventilation

• Pharmacological

  • Bronchodilators

  • Decongestants

  • Expectorants

    • Thins out secretions

• Non-Pharmacological

  • Increase fluid intake

Nursing goals for Impaired Spontaneous Ventilation patients

• Patient will be able to expel secretions with ease

• Patient will have clear breathing

Patients most prone to Impaired Skin Integrity

• Immobilized patients (due to pressure ulcers accumulating)

Nursing interventions for Impaired Skin Integrity patients

• Reposition Q2H

• Heal pressure injury

  • Relieve pressure

  • Optimize wound care

  • Nutrition support + Hydration

• Adhere to treatment plan

Patients most prone to Self-Care Deficit

• Stroke patients

• Elderly patients

Nursing interventions for Self-Care Deficit patients

• Assist pt with ADLs

• Help promote independence in pt

Patients most prone to Risk for Injury

• Pts with mobility issues

• Weak pts

• Diabetic pts with neuropathy

Nursing interventions for Risk for Injury patients

• Fall precautions (bed alarm, lowest position of bed)

• Ensure no environmental hazards (such as carpets)

• Assist with ambulation

• Teach pt to wear non-skid shoes

Patients most prone to Activity Intolerance

• Pts w/ illnesses that affect oxygenation (COPD, Emphysema)

  • Any disease r/t oxygenation issues

Nursing interventions for Activity Intolerant patients

Physically

• Have pt change positions slowly

  • See what pt can physically tolerate

• Gradually ↑ activity and ↓ rest period

Emotionally

• Discuss feelings about activity restriction

• Convey caring attitude/build rapport

Nursing goal for Activity intolerant patients

• This patient will be able to independently transfer to bed/wheel-chair by xx/xx/xxxx date

What is Impaired Adjustment (adjustment disorder)

Pts who have failure/difficulty to cope or adapt with illnesses such as

• Diabetes

• Cancer

• Stroke

• Amputations

Nursing interventions for Impaired Adjustment (adjustment disorder) patients

• Check mental health status

• Check up on how they cope

• Encourage to join support groups

Nursing goal for Impaired Adjustment (adjustment disorder) patients

• Patient has attended support group and is coping well with their diagnosis

ExQ: Patient has impaired sensory perception, what are some concerns you have for this patient

• At risk for injury

  • Due to having reduced/non-existent tactile perception to warmth, feel, etc.

Nursing interventions for Temperature Alteration in Elderly patients

More sensitive to cold or warm environments

• Provide blankets

Nursing interventions for Temperature Alteration in patients with Fever

Pharmacological

• Antibioitics

  • Tylenol

  • Motrin

Non-Pharmacological

• FLUIDS!!!

• Cold compress on forehead, axillae, neck

• Little to no blankets

• If temp is elevated and other VS are normal, ask if pt drank anything cold or hot within 30 min

Nursing assessment for Impaired Respiratory Status patients

• History of respiratory disorders (i.e. COPD)

• Readings of VS & trends

• O2 saturation

• Factors contributing to RR

  • Fever

  • Long-term bed-bound patients

Nursing interventions for Impaired Respiratory Status patients

• Put pt in Semi/High fowler’s position

• Give O2 if <95%

• 2 L nasal cannula

• Incentive spirometer

Nursing assessment for High BP patients

• Look for trends

  • Two or more visits/periodical measurements to properly diagnose

  • Check what patient has been doing the past 3 days, past day, or past hour

Nursing interventions for High BP patients

• Low sodium diet

  • To reduce fluid in body → decreases BV → decreases BP

• Educate lifestyle changes + physical activity

  • Such as aerobic exercises

Patient teaching for High BP patients

• Ask patient to redemonstrate taking their BP before discharge

• Educate proper use + potential side effects of medications

• Teach s/sx of HIGH BP

  • Blurred vision

  • Headaches

Nursing assessments for Alterations in Pulse Parameter patients

• If pulse is thready in one limb

  • Check bilateral pulses

  • If pulse isn’t easily found, use doppler machine

• Also assess for

  • Capillary refills

  • Pallor

  • Cyanosis

Hypotension ranges

• Systolic ≤90 mm Hg

• Diastolic ≤60 mm Hg

S/sx of Hypotension

• Dizziness

• Fatigue

• Concentration problems

• Activity intolerance

• SOB

• Hypovolemic shock

Hypertension ranges

• Systolic ≥120-129 mm Hg

• Diastolic ≥80 mm Hg

Essential/primary hypertension

• Has unknown cause

• Patients may not know they have hypertension

Secondary hypertension

• Diagnosed when there IS a known cause for the increase

• Caused by another medical condition

  • Physiological

  • Endocrine

  • Mechanical

  • Chemical, & etc.

Nursing assessment for Hyper/Hypotension patients

• If CNA checks and BP is abnormally high, recheck yourself

  • If the same, check chart for standing order

    • If none contact PCP has HIGH BP + no standing order

• CANNOT delegate UAP to recheck findings for evaluation

  • NURSES are responsible for reviewing + interpreting findings of VS

Nursing interventions for Hyper/Hypotension patients

• Take several measurements to ensure accuracy

  • Check both arms (bilateral measurements)

• Check if pt is already taking BP meds

  • Reassess BP meds for effectiveness

• ONLY NURSES can interpret the effectiveness of meds

  • Reassess within 15 mins if IV

  • 30 mins if PO

What can be delegated to a CNA regarding VS

CAN DO

• Take VS

  • just can’t evaluate them

• Anything predictable and routined

CANNOT DO

• Assessment of pedal pulses, interpreting med effectiveness, etc.

• Evaluation of VS

• Anything invasive

• Any new intervention or education

SPECIFICATIONS

• Must tell CNA where to take VS on specific pt

  • ex. vasectomy on R breast, check on L arm

• Must tell CNA to hold off temp readings if patient had just taken fluids

  • Alters temp reading

Nursing diagnosis for Thready Pulse

• Fluid deficit

Nursing diagnosis for Bounding Pulse

• Fluid excess

Nursing diagnosis for Altered Nutrition Less Than Body Requirements

• Experience of weight loss

Nursing diagnosis for Tissue Perfusion Alteration

• Patients with cardiovascular disease

• Altered circulation

  • Can cause impaired pedal pulses (weak and thready)

Nursing diagnosis for Cardiac Output Alteration

• If suffering from tachy/bradycardia

Nursing Care for Urinary Incontinent patients

At risk for impaired skin integrity (due to pee pooling up)

• Offer bedpan

• Assist to bathroom

  • Scheduled voiding: Q2H

• Implement Kegel exercises

• Place external condom catheter

• Purewick

Nursing Care for Urinary Retention patients

• Palpate bladder + abdomen for distention

  • Can only palpate IF DISTENDED

• Bladder scan

  • To see how much urine is in bladder

• Drain bladder

  • Catheter

Micturation

• Voiding and excreting of

  • Waste

  • Toxins

  • Drugs

  • Hormones

• If kidneys not working →

  • BP goes up

  • Higher BUN

  • Edema in legs and arms

Which lab value assesses kidneys

• BUN (blood, urea, nitrogen)

Oliguria

• Low urine output

  • Normal: 50-60 mL

  • Oliguria: <60 mL

    • Nurse will notify provider to get urine out via. catheter

Anuria

• No urination

Polyuria

• Excess urination

Dysuria

• Pain during urination

• Common in UTI patients

• Treatment

  • Apply warm pack on perineal area

  • Diuretics

  • Turn water on

  • Ambulation

  • Relaxation

Hematuria

• Blood in urine

Indwelling (foley) catheters

• More permanent catheters

• For patients who

  • Cannot urinate properly

  • Have congestive heart failure

  • Just had surgery

How to Care for Patients with Indwelling Catheter

More prone to UTIs

• If you observe gunk

  • Change/remove it

Patient teaching of Pelvic Floor Muscle Rehabilitation (kegel) Exercises

• Pee for 5-10 sec, then hold pee midtream for 5-10 sec

  • Repeat

    • Improve muscle tone

• CAUTION, patient should not be doing PFMEs while urinating

  • May cause backflow of urine (should only be practiced sitting or laying down)

Visual Loss Patients

• COMPLETE loss of vision

Visual Deficit Patients

• PARTIAL loss of vision

  • e.g. patient has cataract

Nursing interventions for Visual Deficit patients

SAFETY!!!

• Ensure patient has no rugs + bars in bathroom

• Assistance with patient getting up

Nursing interventions for Hearing Deficit patients

• Make sure patient understand you + has hearing aids on

• Talk in better ear

• Talk clearly, concisely, & loudly

• Hold their hand while speaking

Nursing interventions for Gustatory Deficit patients

• (!) Assess mouth for sores

• DON’T give hot food

• Ask food preferences + favorite food

  • May help patients regain/train taste

Nursing Interventions for Olfactory Deficit Patients

• Aromatherapy

• DO NOT mix foods

  • Allow patient to smell foods one at a time

• Label foods for expiration

  • Cannot smell foods going bad

Nursing interventions for Impaired Tactile Perception (Impaired Sensory) patients

• Place precautions as patient has higher risk for injury

  • Due to lack of receptors identifying stimuli

Discharge teaching with Sensory Deficit patients

• Assess what’s in their home environment

• Teach how to use assistive devices

• Should involve social services

Strategies to enhance communication w/ Sensory Deficit patients

• Face the client directly

• Speak clearly

• Use visual aids if needed

• Ensure hearing aids or glasses are in place

• Reduce background noise

• ASL translator if necessary

• Respond to feelings and use gestures

• Orient them to reality

ExQ:  If patient asks for their already deceased husband (has dementia) what can you do to help them

• Instead of saying “your husband passed away”, Redirect and tell them “you must really miss your husband…”

Patient teaching for Patient-Controlled Analgesia System (PCA)

• Pt must be ALERT + ORIENTED

• Emphasize to not let others touch button

• Patient clicks button to self-administer dose

  • Once max dose reached = cannot administer another dose until next dosing time

Evaluating effectiveness of Pain Management Program

• Pain assessment (such as p scales) before and after interventions

• If pain management doesn’t work

  • Start nursing process over and try alternative

  • Involve provider to modify plan

    • Dosage, frequency, drug?

Effects of unrelieved pain on Endocrine System

• Excessive release of hormones

  • ACTH

  • ADH

  • Catecholamines

  • Cortisol

  • GH

  • Glucagon

• Decreased insulin & testosterone lvls

• Causes hormone shift

What unrelieved pain on Endocrine System causes

• Hormone shift in activating

  • Carbs

  • Fat catabolism

  • Protein

  • Hyperglycemia

  • Poor glucose use

What unrelieved pain on Endocrine System results in

• Weight loss

• Tachycardia

• Fever

• Increased RR

• Death

Effects of unrelieved pain on Cardiovascular System

• Hypercoagulation (blood clots too easily/abnormally)

• Increased

  • HR

  • BP

  • Cardiac overload

  • Oxygen demand

Effects of unrelieved pain on Respiratory System

• Pneumonia

• Atelectasis

• Shallow breathing

  • Limits thoracic + abdominal movement to reduce pain & splinting

• Hyperventilation

• Respiratory acidosis

Effects of unrelieved pain on Musculoskeletal System

• Impaired muscle function

• Fatigue

• Immobility

Effects of unrelieved pain on Genitourinary System

• Decrease in urinary output

• Urinary retention

• Fluid overload

Effects of unrelieved pain on Gastrointestinal System

• Gastric emptying

• Intestinal secretions

• Smooth muscle tone increase

• Motility decrease

Proper body mechanics when providing patient care (to prevent risk of injuries)

• Body mechanics

  • Bend at knees

  • Proper alignment

  • Keep back straight

  • Avoid twisting & turning (especially by yourself)

  • Push vs lift

Common practices for body mechanics when providing patient care (to prevent risk of injuries)

• Common practices

  • Ask for assistance

  • Avoid manual lifting as much as possible

  • Make sure bed wheels are locked

Nursing treatment to decrease risk of Joint Contracture

• AROM

  • Done independently

• PROM exercises

  • Assisted ROM

Assessments before transferring patients

• If they have full or partial weight bearing

• Ask if they use assistive devices

• Orthostatic hypotension?

• Fall risk?

• LOC?

• Guide them to an assisted fall (if they fall)

  • PROTECT HEAD

  • Allow them to slide down side of your body/leg

Transfer Board Use

• For pts w/ good upper body strength, but limited lower body mobility

  • Spinal cord injuries

• Transfers pt from one surface to another w/o lifting (bed → gurney)

Mechanical Lift Use

Also Hydraulic Device

• Completely lifts home care, immobile or obese patients

  • Helps prevent caregiver injury

Standing Assistive Device Use

• Helps pt stand who can bear some weight

Friction-Reducing Device Use: Transfer/Roller sheet

• Thin, low friction sheets that’s placed under drawsheet

  • Helps facilitate moving patient in bed

  • Mainly used to transfer pts who are COMPLETELY IMMOBILE

Friction-Reducing Device Use: Scoot Sheet

• Similar to Transfer/Roller sheet, but is attached to a mechanical crank

Friction-Reducing Device Use: Roller Tray

• Used to reduce low back stress when moving patients

Friction-Reducing Device Use: Transfer Belt

• Helps facilitate transfer be holding patient when ambulating

Cataplexy

• Sudden loss of muscle tone

  • Usually triggered by emotional events

Hypersomnia

• Excessive sleeping (especially during the day)

  • Patients are suspended from driving

• Make sure pt has access to home health aid or family member who can assist

(!) NARCOLEPSY

• Patient falls asleep anywhere and at anytime

  • Wakes up spontaneously refreshed (weird)

  • At risk for injuries

MOST LIKELY ON EXAM

Sleep Apnea

• Periodic interruption in breathing during sleep

(!) Sleep Assessment Used to Confirm Diagnosis of Sleep Apnea

• Use of polysomnography

  • AKA. Sleep Study

Patients at risk for Sleep Apnea

• Obese

• Elderly

Treatment for Sleep Apnea

• BiPAP (Bilevel positive airway pressure) or CPAP

  • Helps regulate breathing at night

ExQ: Patient seems very sleepy, and by the next second, patient suddenly appears wide awake. Patient also has no recollection of episodes that just ocurred. What is this an example of?

• Narcolepsy