Nursing Exam #3

Stressor

Anything that causes stress

Appraisal

how someone interprets stress

Crisis

overload with the amount of stresss

Trauma

experiencing signs and symptoms of stress but they last over a period of time

Coping

tools we use to help us deal with stressors

compassion fatigue

giving so much of yourself all the time you get tired

burnout

overexteding again but people aren't stressing you out work factors and work are

resilience

the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress

What does GAS stand for?

General Adaptation Syndrome

What is GAS?

our stress respone system defends then fatigues

What is Phase 1 of GAS?

alarm reaction: flight or fight

What is Phase 2 of GAS?

resistance: trying to cope with stressor, body tries to bring down sympathetic response

What is Phase 3 of GAS?

exhaustion: can no longer stay in the resistence stage of stressor

Sympatheic Nervous System Response

look at picture in power point.. Page 4

What are Physical stress symptoms?

-aches and pains, muscle tension, headache
-chest pains
-nausea
-diarrhea, constipation
-loss of sex drive
-frequent colds

What are cognitive stress symptoms?

-impaired learning
-inability to concentrate
-intrusive thoughts
-memory problems
-poor judgement
-seeing only the negative
-constant worrying

What are emotional stress symptoms?

-mood changes
-agitations
-anxious
-overwhelmed
-decreased self-esteem
-feelings of worthlessness
-depression

What are social stress symptoms?

-withdrawn
-sense of loneliness and isolation
-conflict with family and friends

What are behavioral stress symptoms?

-eating more or less
-sleeping more or less
-isolating
-procrastinating
-using alcohol, drugs
-nervous habits

What are some ways to cope with stressors?

-get good sleep
-eat good food
-exercise
-belly breathing exercises
-talking to friends or family
-changing how you view stress
-seeking help from mental health resources

Difference between compassion fatigue and burnout?

compassion fatigue originates from dealing with people who are stressed, burnout deals with you receiving stress from your job

What are the types of pain?

-acute-lasts less than 6 months
-chronic-last over 3 months post-op, or 6 months beyond the normal healing period
-Nociceptive-Visceral (from organs)
-Somatic (from skin, muscles, bones, or joints)
-Referred (originates in a different place than where it is being felt)
-Radiating (entends from source to adjacent part of body)
-Neuropathic-results from nerve injury
-Psychogenic-no physical cause, related to mental, emotional, or behavioral factors

What are some pain assesment tools?

-Numeric Rating Score- rating pain from 1-10
-Wong-Baker FACES Pain Rating Scale-used when a person might have trouble expressing pain
-PainAD-Objective pain score used to determine pain in people living with dementia
-CRIES scale-used in people 6 months or younger, often used in neonatal ICU's

LOOK AT PAGES 8 AND 9 IN PPOINT TO SEE EXAMPLES

How can pain affect the body?

-can raise blood pressure
-increase breathing rate
-can cause muscle tension
-can make you tired
-can have changes in appetite

what are some methods of pain management?

-Complementary and alternative therapies-helpful with mild pain, and can be used alone or in conjunction with medication
-Herbal-ginger, rosehips, turmeric, black cohosh
-Biofeedback-using voluntary control to relieve muscle tension
-Mediation
-Aroma Therapy
-Hypnosis
-Acupuncture
-Acupressure
-Cupping

what are other methods of pain management?

-Palliative care-any person experiencing pain related to illness can benefit from a palliative care consult

other methods of pain management

-Pharmacologic- nonopioid analgesics-used to treat moderate pain (1-7)
ex. acetaminophen, nonsteriodal anti-inflammatory drugs, inflammatory pain or bone pain
-Opioid analgesics-used to treat moderate to severe pain (7-10)
ex. oxycodone, hydromorphone, fentanyl, meperidine, morphine

what are common side effects of analgesics?

-Nonopiod and opioid analgesics (dependence on drugs)
-NSAIDs (GI upset, bleeding) *if patient has cardiac or renal issues this class of drug may be contraindicated
-Acetaminophen (don't exceed a total daily dose of 3000mg, long term use can cause liver damage, renal damage, leukopenia (decrease in white blood cells)
-Opioids (respiratory depression, seizures, nausea, vomiting, constipation, itching, urinary retention, drowsiness

what are types of wounds?

-Broad categories (open v closed, acute v chronic)
-Descriptions (abrasion, laceration, puncture, contusion)
-Classification of surgical wounds (clean, clean/contaminated, contaminated, infected)

what are the 4 phases of wound healing?

Hemostasis
Inflammation
Proliferation
Maturation

what happens in the hemostasis stage of wound healing?

once you cut yourself, you need to stop the bleeding so your vessels constrict so that not as much blood is coming out. While constricting your vessels it's also sending out signals to tell your platelets to come together to make a platelet plug. overtime fibrin comes to close the area and form a scab.

what happens in the inflammatory stage of wound healing?

they are the clean up crew, sending out chemial signals saying they need a little help beyond the platelets, so they move on to the white blood cells (leukocytes, neutrophils, and macrocytes) to pull bacteria off of wound and move it away.

what happens the proliferation stage of wound healing?

filing the wound, and covering the wound. the cells will fil in from the top layer, if it's deeper (start from the bottom of the wound and fill to the top. angio is making new blood cells, granular- is when the new cells pill in together to fill up the space. Collagen is used to make sure the wound stays moist.

what happens in the maturational stage of wound healing?

Stage of remodeling phase
everything closes up, wound contracts, starts to shrink and go back to normal, may take weeks to months to reach the original strength.

Surgical healing (PRIMARY)?

-Wound is clean, in a straight line, with little loss of tissue
-All wound edges are well approximated with sutures
-usually rapid healing with minimal scarring

Would occur after surgical incision.

Surgical healing (SECONDARY)?

-Large wound with considerable tissue loss
-Natural healing by formation of granulation tissue
-Healing takes longer and results in more scarring
ex. pressure ulcer

Would occur when a wound that cannot be stiched causes a large amount of tissue loss.

Surgical healing (TERTIARY)

-time delay before wound is sutured
-greater granulation, greater risk for infection, greater inflammatory reaction than primary intention
-let the wound heal from the bottom to the top (leave wound open)


Would occur when the wound appears clean and there's evidence of good tissue vability and tissue perfusion

How to identify signs of infection in a wound?

would do a wound assessment
-look at the wound bed (only on open wounds)
red=healthy
yellow=slough in wound
black=debris in wound bed

what are the types of drainage?

Serous: clean, watery
Sanguineous: bright red
Serosanguineous: pale, red, watery mixture of serous and sanguineous
Purulent: thick, yellow, green, tan or brown

Care of surgical wounds.

-for simple cuts (clean area and then stitch up)
-for deeper open wounds (pack with gauze)

Care of surgical drains.

-Put in drain from inside of body to outside (have safety pin to keep drain from slipping into the wound
-jackson-pratt drain
-Hemovac

What are some surgical wound complications?

-Dehiscence-after you sew a wound up the sutures break revealing a slit from the surgical site
-Evisceration-after sewing a wound up the sutures break and organs start spilling out, like bowel
-Infection

What are pressure ulcers?

area over a bony part of the skin where there is a decrease in blood flow.

What are some risk factors of pressure ulcers?

shear v friction
friction wounds-caused when skin rubs against another object (rug burn)
shear wounds- skin moves one way but bones and other things are moving in th opposite direction, their is a deeper tissue injury

what are some ways to prevent skin breakdown?

-Hygiene/Skin care
-Positioning
-Support surfaces
-Nutrition/hydration
-Frequent assessment

What does stage 1 of having a pressure ulcer look like?

Intact skin with a non-blanchable redness of a localized reddened area

what does stage 2 of having a pressure ulcer look like?

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ ruptured serum-filled blister

what does stage 3 of having a pressure ulcer look like

full thickness skin tissue loss, deep crater with or without undermining of adjacent tissue. Subcutaneous fat may be visible but bone, tendon of muscle are not exposed. May include undermining and tunneling.

what does stage 4 of having a pressure ulcer look like

full thickness tissue loss with exposed bone, tendon or muscle. slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling