adult health pre midterm 1

stress related to

• leading causes of death

• can cause people to seek healthcare

• affects nursing care bc adpie aims to prevent, identify and alleviate stress

stress definitions

• individualised reaction or response to a stimulus when real or perceived demands exceed one’s available coping resources

• response of the body to any demand made on it (diverse noxious agents)

• traditional research focused on physiological stress, current research looks at emotional, psychological and spiritual stress

• stress is a response to demands on the mind or body

• its a perception

  • perception that one cant cope with demands

  • personal meaning attached to a potential stressor

types of stress

• physiological (chronic pain, starvation, noise)

• emotional

• psychological

• (emotional and psychological) (diagnosis, marital problems, grief)

factors affecting stress response

internal coping and external coping

personal characteristics: resilience, attitude, sense of coherence, hardiness, optimism

general adaptation syndrome

• physical response to stress

• 3 stages

  • alarm/reaction

  • stage of resistance

  • stage of exhaustion

GAS- alarm/reaction

• perception of stressor (physically or mentally)

• fight or flight response initiated

• temporarily decreased resistance

• increased HR, dilated pupils, increased RR, decreased bowel motility, constricting blood vessels, increased cardiac output, breakdown of glucagon into glucose

GAS- resistance

• transition from alarm to resistance is quick

• fewer overt physical signs but adaptation occurs

• changes happen, prepare to take on stressor, or person advances to exhaustion

GAS- exhaustion

• occurs when all energy for adaption has been exhausted

• physical symptoms of alarm reaction may briefly appear again as a final effort

• stage can be reversed by external sources

body systems during stress

NOTES

nervous system during stress

cerebral cortex- plans course of action after evaluating stress with past experience and future consequences

limbic system- mediates emotions, feelings and behaviors to ensure survival and self-preservation

reticular formation- send alertness impulses to limbic system and cerebral cortex, stress increases alertness impulses, leads to wakefulness and sleep disturbances

hypothalamus- connects nervous and endocrine system, regulates function of sympathetic and parasympathetic branches of ANS

***cortisol, stress hormone

immune system during stress

effects of stress

• can lead to physiological changes

• maladaptive response leads to harm and disease (ex- substance abuse)

• cognitive function, behavior, excessive activation of sympathetic nervous system, immunosuppresion

coping

cognitive and behavioral efforts to manage internal or external stressors

positive vs negative coping

emotion focused: managing emotions that person feels when event occurs (when person doesn’t have control over stressor)

problem focused coping: finding solutions to resolve problems causing the stress

coping resources: health status, belief systems, problem solving skills, social skills and support, financial

relaxation strategies

***understand guided imagery bs imagery

adpie assessment of stress

• aware of situations likely to result in stress

• assess pt’s perception of situation and coping used

• s+s: bp and hr, hyperventilation, headache, anxiety, irritability or impaired speech, self reports of forgetfulness or indecision

adpie diagnosis of stress

• ineffective coping (inadequate confidence in ability to cope, inadequate social support or resources, uncertainty, high degree of threat)

• compromised family coping (usually supportive primary care giver provides insufficient or compromised support)

adpie implementation of stress

• identify and express stressful feelings

• facilitate and enhance processes of coping and adaptation

• encourage pt/family to seek info related to treatment

• strategies (on a prev slide)

• recognise when a pt needs to be referred to a professional for counselling

chronic illness

health condition that persist over extended periods, often (not always) associated with participation and activity limitations (disability), tobacco use, unhealthy diet and harmful use of alcohol

characteristics of chronic illness

• persists over extended periods of time

• longer onset

• rarely cured or eliminated

• exacerbation and remissions

• phases (crisis, chronic, terminal)

• often no single direct or identifiable cause

terms

acute- fast onset, treatment

chronic illness- long term

exacerbation- flare up or worsening of symptoms

remission- symptoms not as visible right now (DOES NOT MEAN ILLNESS IS GONE)

sign- objective

symptom- subjective

comorbidity- additional diseases or disorders (2 or more diseases/disorders)

multimorbidity- 5 or more diseases or disorders

disease- pathophysiological and diagnosed by physician

illness- patient perception of condition

health- general state of well being

leading chronic illness in canada

cancer

other ex- cardiovascular, resp diseases, chronic kidney failure, diabetes, mental illness

risk factors for chronic illness

modifiable vs non modifiable

chronic illness impact on population

increased morbidity (population with diseases and illness)

increased mortality (population dying of diseases)

chronic illness among Indigenous ppl

• higher rates compared to average

• prone to: diabetes, hep c, HIV, heart disease, high bp

healthcare management in canada

usually focuses on acute or episodic care, don’t really focus on chronic illness or people who live in the community (75% of deaths are chronic illness)

self management

• daily activities that individuals undertaake to keep their chronic illness under control

• leads to better overall physical and psychological health outcomes

• use various strategies to maintain a normal life

• may hide or conceal disease

• healthcare workers need to encourage self management as it leads to better outcomes

caregiver burden

• physical, emotional and financial costs of caregiving over time

• burnout

role of nurse during self management

• be sensitive to strategies used by patients

• explore if strategies are helpful or maladaptive

• empower patient

• ensure autonomy in adjusting the treatment regiment as necessary

• encourage adherance and self care management

med surg nursing

working in all units

challenges in future

• evolving roles

• shifting emphasis of roles

• increasing tech, need to be up to date

pain

• causes suffering and reduces quality of life

• #1 reason for ppl coming in to seek healthcare

• nurses have central role in assessment and management

• effective pain management is a basic human right

nurses role in pain

• assess, document and communicate about it

• delivery of effective pain relief

• evaluate effectiveness of interventions

• monitor ongoing effectiveness of pain management

• pain is subjective and that is challenging

• provide education to patients and their families

pain problem

why is pain undertreated

• inadequate skills to treat and assess pain

• misconceptions abt pain

• inaccurate info abt addiction and opioids (lowest dose possible for best pain control and least side effects)

• nonmalificence (not wanting to harm the patient)

what is pain

• whatever the patient says it is

• not synonymous with suffering

• unpleasant sensory and emotional experience

• with or without disease or injury

• multidimensional

• difficult when working with nonverbal or cognitively unable to rate pain, use nonverbal information and behaviors

understand pain as talked abt in hollistic and psych

describing pain

nociceptive (somatic)- S structure/surface - skin, muscles, bones, joints (localised)

nociceptive (visceral)- Vital organs - bowel, kidney, heart, appendix (deep organ pain) (less well localised)

neuropathic - N - Nerves

acute vs chronic pain

basal medications - scheduled medication, taken for baseline (chronic pain)

prn medications - for acute pains

breakthrough pain - for pain that goes beyond normal management (ex for those with chronic conditions, the pain is more than the basal medication manages)

pain assessment

Indigenous considerations with pain

• high rates of persistant pain

• awareness of discrimination related to substance misuse and pain issues

• acknowledgement and understand experiences related to historical social issues to be culturally sensitive

equinanalgesic dose

• dose of one analgesic equivalent in pain reliving effects compared with another analgesic

• important when substituting one analgesic for another and when changing the admin route of opioids

titration

• dose adjustment based on assessment of analgesic effect vs adverse effects

• use smallest dose to provide effective pain control with the fewest adverse effects

scheduled analgesics

• prevention or ongoing control

• do not wait for severe pain to occur

• constant pain requires scheduling

• fast acting for incident or breakthrough and long acting for constant pain

analgesic ladder

rating pain: 1-3, 4-6, 4-10

step 1, mild pain: non opioids (with or without adjuvant)

step 2, mild to moderate pain: mild opioids (step 2) given with step 1 medications

step 3, moderate to severe pain: stronger pain: strong opioids (step 3) (mu receptor agonists) these drugs are more potent, no analgesic ceiling, delivered via many routes

ceiling effect

increasing the dose beyond upper limit provides no greater analgesia

step 2 medications

• given for mild to moderate or moderate to severe pain

  • Mu: morphine, oxycodone, hydromorphone, methadone

  • opiod agonists- morphine

  • opioid antagonist- naloxone

  • mixed agonist antagonist (pentazocine, butorphanol) shouldn’t be used bc they bind as agonists at the mu receptor

nsaid med warnings

NSAIDS (not aspirin) linked to higher CV events

pts who have just had heart surgery should not take nsaids

opioid med warnings

opioids may cause resp depression

withhold opiods if resps are under 12 per minute

transdermal fentanyl shouldnt be used for acute pain|

adjuvant analgesic therapy

• used with non opioids and opioids

• sometimes called co analgesics

• enhance pain therapy by:

  • enhancing effect of opioid or non opioid

  • possessing analgesic properties of their own

  • counteracting adverse effects of other analgesics

admin routes for medication

non pharmacological pain therapy

• reduced amt of analgesics required (minimises adverse effects)

• possible alters ascending nociceptive input or stimulates descending pain modulation mechanisms (REWORD)

• ex: massage, excersize, transcutaneous electrical nerve stimulation, heat therapy, cold compress, cognitive techniques like distraction, relaxation and self management

tolerance

need more med for equal pain control over time

physical dependance

expected response to exposure to meds, manifested by withdrawal when levels drop, medication should be slowly weaned to avoid

substance misuse

• tolerance and physical dependence are not indicators of addiction or substance misues

using a substance in high doses or inappropriate situation, can lead to health and social problems

ethical issues in pain management

fear of hastening death by administering analgesics

use of placebos in pain assessment and treatment

age related considerations for pain

• persistent pain (common- musculoskeletal)

• pain in elderly inadequately assessed and treated

• results in depression and functional impairments

• barriers to treating pain: belief that pain is part of agining, fear of using opioids, words like aching, soreness or discomfort

• treatment cautions: older persons metabolise meds slower, greater risk for AE, risk of GI bleeds with nsaids, multuple med use (watch for interactions), cognitive impairment and ataxia can be exacerbated

considerations for cognitvely impaired individuals

• may prevent pts from clearly communicating

• use behavioral and physiological changes may be the only indicators of pain

• scales to assess pain in cognitively impared person are based on behavior

  • vocalisations

  • expressions

  • breathing

  • body movements or tension

• inability to validate meaning of behavior prompts nurses to rely on pts usual (baseline) behavior, if nurse is unaware of baseline ask family or other caregivers

considerations for pts with substance use issues

• right to receive effective pain management

• assess and provide relief with a dual diagnosis of pain and substance use disorder is imperative

• establish treatment that will relieve pain and minimize withdrawal

• usually requires interprofessional approach

homeostasis

• state of equilibrium in body

• naturally maintained by adaptive responses

• body fluids and electrolytes are maintained within narrow limits

water content of the body

70-80% in infants

60% in adults

45-55% in older persons

*% of body weight, varies with sex, body mass and age

lab values to know

Na+ 135-145

K+ 3.5-5.1

Cl- 96-106

BUN 2.9-8.2 (M/F)

Creat 44-106 (M/F)

Hgb 120-180 (M/F)

Hct 0.37-0.52

fluid compartments of the body

intracellular fluid (ICF) (~28L)

extracellular fluid (ECF) (~13L)

• intravascular (plasma, fluid inside vessels) (~3L)

• interstitial (fluid around the cells) (IF) (~1L)

• transcellular

electrolytes

• substance we take in through foods

• substances whose molecules dissociate into ions (charged particles)

  • cations are positive

  • anions are negatime

• measured in millimoles per litre mmol/L

electrolyte composition

ICF

• prevalent cation is K+

• prevalent anion in PO4 ³^-

ECF

• main cation is Na+

• prevalent anion is Cl-

mechanisms controlling fluid and electroyte movement

diffusion

facilitated diffusion

active transport

osmosis

hydrostatic pressure

oncotic pressure

diffusion

• moves molecules from high to low conc

• occurs in liquids, solids and gases

• membrane separating 2 areas must be permeable

• no energy

facilitated diffusion

• movement of molecules from high to low conc without energy

• uses carrier molecules or proteins to accelerate diffusion

active transport

• molecules move against concentration gradient

• external energy required

• ex- sodium potassium pump

osmosis

• movement of water btwn 2 compartments by a membrane permeable to water but not solute

• moves from low solute to high solute conc

• requires no energy

• albumin (protein, larger than electrolyte- can’t go inside cell membrane) found inside blood vessel, holds fluid inside intravascular space

osmotic pressure

• amt of pressure required to stop osmotic flow of water

• determined by conc of solutes in solution

• osmotic pressure, pulls water into vessel

  • low osmotic pressure causes more fluid in tissues

  • high osmotic pressure causes more fluid in vessels

effects of water status on rbc

Tonicity

more solute in cell causes more water to go in- hypotonic (think LOW conc OUTSIDE cell)

less sulute in cell causes water to leave- hypertonic (think HIGH conc OUTSIDE cell)

isotonic: normal saline or lactated ringers, mirrors composition of blood to avoid cells shrinking or swelling

hydrostatic pressure

• antagonistic to osmotic pressure

• force within fluid compartment

• major force that pushes water out of vascular system at capillary level

oncotic pressure

osmotic pressure exerted by colloids in solution

• protein is a major colloid

• this pressure does the pulling of proteins like albumin, keeping them in the vessels

crystalloid

• solutions you can see through

• dissolved substances

colloids

• proteins like albumin, even a bag of blood

• solution not clear, not dissolved

fluid movement in capillaries

• capillary hydrostatic pressure

• plasma oncotic pressure

• interstitial hydrostatic pressure

• interstitial oncotic pressure

fluid shifts

re word

fluid volume excess- gain or retention of excess water, more water into tissues and cells, peripheral edema, *ascites, crackles, daily weights required for these pts (1Kg = 1L)

fluid volume defecit aka hypovolemia- symptoms that result from cell shrinkage as water pulled into vascular system, dryness, causes urine retention, low bp, faster hr, dry skin, mental status changes- disorientation or headache, dizziness, muscle cramps

***

fluid shifts

first spacing

• normal distribution of fluid in OCF and ECF

second spacing

• abnormal accumulation of intersitial fluid (peripheral edema), body can work to return to first spacing

third spacing

• fluid accumulation in part of body where it is not easily exchanged with ECF (ascites), this fluid has to be drained

hypothalamic regulation of water

• osmoreceptors in hypothalamus sense fluid deficit or increase and receives the signal

• stimulate: thirst and antidiuretic hormone release (ADH)

• result in increased free water and decreased plasma osmolarity

pituitary regulation of water

• under control of hypothalamus, posterior pituitary releases ADH

• stress, nausea, nicotine and morphine also stimulate ADH

  • ADH- causes less water to be peed out, water retention

adrenal cortical regulation of water

• releases hormones to regulate water and electrolytes

• glucocorticoids- cortisol and minteralcorticoids- aldosterone

renal regulation of water

• kidneys are primary organs for regulating fluid and electrolyte balance

  • adjust urine volume by selective reaabsorption of water and electrylytes

  • renal tubules are sites of action of ADH and aldosterone

summary of fluid and electrolyte balance

cardiac regulation of water

• atrial natriuretic factor (ANF) is a hormone

  • produced by cardiomyocytes in response to increased atrial pressure

  • primary actions are vasodilation and increased urinary excretuion of sodium and water, decreases blood volume

GI regulation of water

• oral intake accounts for most water

• small amts are eliminated by GI tract in feces

• diarrhea and vomiting can lead to significant fluid and electrolyte loss

insensible water loss

• invisible vaporisation from lungs and skin to regulate body temp

• approx 900mL/day

• no electrolytes loss

age related considerations for water

fluid and electrolyte imbalances

• common in pts with major illness or injury

• caused by illness or dieases (ex- burns or heart failure)

• result of therapeutic measures (IV fluid replacement or diuretics)

• for healthy individuals- fluid amts will vary by day or activity but body can adjust to it

extracellular fluid volume imbalances

ecf volume defecit (hypovolemia): abnormal loss of normal body fluids by diarrhea, fistula drainage, hemorrhage, inadequate intake or plasma to interstitial fluid shift

• treated by replacing water and electrolytes with balanced IV solutions

fluid volume excess (hypervolemia): excessive intake of fluids, abnormal retention of fluids (HF) or intersitial to plasma fluid shift

• remove fluid without changing electrolyte composition or osmolarity of ECF

stopped on slide 41