NURS 266 FINAL

Vital Signs

* temperature

96\.8°- 100.4° F (36°-38°)

Vital Signs

* pulse

* 60-100 beats/min

Vital Signs

* resp rate

12-20 breaths/min

Vital Signs

* bp

Vital Signs

* pain

scale from 0-10

When do you take vital signs

• upon admission/routine scheduling (every 4-8)

• B4, during, and after surgery

• every 5-10 min when PT’s condition worsens

Body Temp

* formula

heat produced - heat lost = body temp

Factors affecting Body Temp

• exercise

• anxiety

• age

• hormonal level

• stress

• environmental

Hyperthermia

very HIGH body temp

Hypothermia

very LOW body temp

Heatstroke

body temp rapidly rises

* body is unable to cool down

Heat Exhaustion

body’s response to an excessive loss of water & salt

Temp Measurement

* continuous

• pulmonary artery

• esophagus

• urinary

Temp Measurement

* Intermittent

• oral

• axilla

• skin

• rectal

• tympanic membrane

• temporal artery

What is a fever (pyrexia)

heat loss mechanisms are unable to keep pace w/ excessive heat predoduction

Febrile

showing s/s of fever

Afebrile

NO s/s of a fever

How does the body respond to a fever?

• tries to regulate

• increase WBC count

• vasoconstriction

What is the purpose of taking Apical Radial Pulse?

to determine the presence of a pulse deficit

* 2 nurses take 2 different pulses

The Nature of Pain

• pain is subjective

• pain reduces quality

• NOT measurable objectively

Physiological Response to Pain

• fight or flight

• pain impulses ascend the spinal cord toward brainstem & thalamus

• the stress response stimulates the autonomic nervous system

Factors Influencing Pain

• fatigue

• age

• genes

• attention

• family & social support

• spirituality

• ethnicity (meaning of pain)

• previous experiences

Psychological Factors Influencing Pain

• anxiety

• coping style

Pain Tolerance

the level of pain a person is willing to accept

Types of Pain

* Acute/Transient

• short duration

• identifiable

• protective

Types of Pain

* Chronic

• has NO purpose

• may or may not have an identifiable cause

Types of Pain

* Chronic Episodic

• occurs sporadically

• over an extended duration

Types of Pain

* Idiopathic

* chronic pain w/o identifiable physical/ psychological cause

Classification of Pain

* Cutaneous/Superficial

• short duration

• localized

  • ex: needle stick, cut, laceration

Classification of Pain

* Visceral/Deep Somatic

• internal organ pain

• hard 2 localize

Classification of Pain

* Radiating

pain is extending from 1 side to another

Classification of Pain

* Phantom

pain is in a limb that is NO longer there

Classification of Pain

* Psychogenic

brain believes there pain when there is no identifiable cause

OLDCART

**O**rigin

**L**ocation

**D**uration

**C**haracteristics

**A**ssociated manifestations

**R**elief?

**T**reatment?

ABCDE

* think pain

**A**sk about pain regularly

**B**elieve PT & family in their report of pain

**C**hoose pain control options appropriate for PT

**D**eliver pain interventions in a timely/logically/function

**E**mpower PT & their family

NON PHARM pain relief interventions

• guided imagery

• massage

• music

• journaling

• humor

• cold/hot compress (w/dr orders)

Pharmacological Interventions

* Non-opioids analgesia

• NSAIDS

• Acetaminophen

Pharmacological Interventions

* Opiods

• PCA pump

• Narcotics

Pharmacological Interventions

* Adjuvant

• antidepressants

• anti-seizure

• relaxants

• steroids

Body’s Reaction to Unrelieved Pain

• increases HR, BP & O2

• increased workload

• shallow breathing

• depression/anxiety

• too many hormones are released

How do we document pain

• pain assessment

• pain management

• PT response

• updated pain assessment (re-assess)

What is body mechanics?

coordinated movements of the MS & nervous system

Mobility

ability to move freely

Immobility

inability to move freely

Principles of Body Mechanics

* for nurses

• wide base of support

• raise beds

• keep objects close to your center of gravity

• DO NOT REACH

• push/slide heavy objects

• maintain good grip

What is needed to support movement of body?

• body alignment

• balence

• gravity

• joints/ligaments/tendons

• proper posture

Friction

force that occurs in a direction to oppose movements

Shearing

occurs when the force exerted against skin while the skin remains stationary

Factors That Affect Mobility

• MS trauma

• damage to CNS

• postural abnormalities

• muscle abnormalities

• disorders of bones, joints, muscles

• developmental change

Risk Factors of Immobility

• MS deconditioning

  • disuse atrophy

• Bed rest

  • skin deteroration

  • depression & short temper

  • social isolation

Disuse Atrophy

cells/tissues decrease in size & function

Hazards of Immobility

* metabolic

• dehydration

• edema

• loss of SQ tissue

• nutritional imbalances

Hazards of Immobility

* Respiratory

• shallow respirations

• abnormal RR pneumonia

Hazards of Immobility

* Cardiac

• edema

• impaired circulation

• DVT

• pulmonary embolism

• orthostatic hypotension

Hazards of Immobility

* MS

• decrease muscle mass

• risk for osteoporosis

• decreased strength of muscles

Hazards of Immobility

* Integumentary

* risk for skin breakdown
* pressure ulcer

Hazards of Immobility

* Elimination

• constipation

• UTI

• paralytic illeus

• urinary retention

• kidney stones

Hazards of Immobility

* Psychosocial

• depression

• confusion

• isolation

• sleep disturbances

ASSESSMENT of Mobility/Immobility

• assess health HX

• assess ROM

• assess posture/gait/body alignment

• assess activity tolerance

• assess hazards of immobility

Preventing Falls

* for PT’s

• teach proper body mechanics

• teach fall pecautions

• teach safety

• use bed alarm

• use assistive devices

Nurs. Diagnosis: Mobility/Immobility

• risk for disuse syndrome

• risk for impaired skin integ.

• risk for impaired tissue perfusion

• fatigue

• risk for injury

• social isolation

• risk for constipation

Nurs. Interventions: Mobility/Immobility

• provide ROM

• promote exercise/activity

• promote ADL’s

• promote bone health

• encourage proper nutrition

• use support devices (gait belt/trochanter roll)

Positioning Techniques

• supine (flat)

• semi-fowlers (30°-45°)

• fowlers (45°-60°)

• high fowlers (almost @ 90°)

• lateral (laying on uneffected side)

• Prone (laying chest down)

• Sim’s (L. lateral)

• Transdelenburg (for severe hypotension)

What is needed to ensure activity safety?

• body alignment

• balence

• gravity

• CARDIAC CLEARENCE

• coordinated movements

Nurs. Interventions: Activity & Exercise

• encourage PT to participate in exercise

• plan w/ physical therapy

• provide safety

• assist w/ transfers

• assist w/ gait

Active ROM

PT is able to move their own joints

Passive ROM

Nurse has to move PT’s joints

Assisting Safety w/ Ambulation

• asses pain B4 moving PT

• take BP before

• how many ppl are requires to ambulate

• ask PT if they are strong enough

Hemiplegia

1- sided paralysis

Hemiparesis

1- sided weakness

• support affected side (side of injury)

What is the goal restorative care

* maximize functional deficits

What is infection

* invasion of susceptible host by a pathogen

Colonization

• within the host

• NO tissue damage

• NO active disease

Communical Disease

able to be transmitted person to person DIRECTLY

Stages of Infection

* Incubation

time it takes for infection to develop after being exposed

Stages of Infection

* Prodromal

infectious agent replicates/multiply (early s/s)

Stages of Infection

* Illness

PT shows s/s of infection

Stages of Infection

* convalescence

s/s resolve

Types of Health Care Associated Manifestations

* exogenous

from outside source (ex: salmonella)

Types of Health Care Associated Manifestations

* endogenous

• flora becomes altered

• OVERGROWTH occurs

  • caused by antibiotic

Types of Health Care Associated Manifestations

* iatrogenic

due to invasive procedure

Chain of Infection

1. pathogen

2. reservoir (source of pathogen)

3. port of exit (from reservoir)

4. mode of transmission

5. port of entry (into host)

6. susceptible host

Virulence

ability to produce disease

Reservoir

source of infection

• location where pathogen thrive

• anaerobic vs aerobic

Portal of Exit

how infection spreads & exits

Mode of Transmission

* contact

• direct

• indirect

Mode of Transmission

* Droplet

water droplets are inhaled or enter through eyes

Mode of Transmission

* airborne

contracted through particles in the air

* ex: TB, COVID, measles

Mode of Transmission

* vector

bite from a mosquito/ticks/flea that spread pathogen

Mode of Transmission

* vehicle

indirectly transmit infection

* ex: water, food, medical instruments

Localized Infection

only wound is infected

* pain, redness, warmth, tenderness

Systemic Infection

affects entire body

Bodys Natural Defense

• normal flora

• tissue repair

• inflammation

• exudate @ site (COCA)

• vascular/cellular response

Factors Influencing Infection

• age

• stress

• nutrition

• sex

• ethnicity

• hygiene

• immunizations

• occupation

• disease process

ADPIE FOR infection control

* assessment

• identify infection

• s/s of infection

ADPIE FOR infection control

* diagnosis

• risk for infection

• acute pain

ADPIE FOR infection control

* plan

• treatment goals/outcomes

• hand hygiene

ADPIE FOR infection control

* implementation

* carry out plan

ADPIE FOR infection control

* evaluation

* re-assess :
* PT
* plan provided
* is infection better or worse

How do we break the chain of infection?

• promote ASEPSIS

• support host defense