Test 2

Role of Psych Tech (Data Gathering)

assist in data collection, pay attention to small details/changes, communication with healthcare team

Objective data

all measurable and observable pieces of information about a client and his or her overall state of health

Subjective data

information that consists of the client’s opinions and feeling about what is happening, conveyed to the nurse either directly or through body language

Anorexia

loss of appetite

Cough

forceful expiration

Edema

swelling of tissues

Fatigue

loss of energy

Pyrexia

fever/elevated body temperature

5 Vital/Cardinal Signs

temperature, heart rate (pulse), respirations, oxygenation, blood pressure~ could die if away from norm

When to take vital signs?

• when ordered

• when sign dysfunction

• taken regularly within hospitals/skilled nursing facilities, start of shift, or per nursing judgement

• taken prior to giving certain meds

• always retake after an out-of-range result

What part of the body regulates body temperature?

hypothalamus~ core temp maintained through balance between heat produced & heat lost

Celsius formula

°C= 5/9 (°F-32)

Fahrenheit formula

°F= (°C x 9/5) +32

*Normal readings: Tympanic (auditory canal):

96.4-100.4°F

Normal body temp

98.6°F = 37°C

Pyrexia/febrile

elevated temp, fever

Fever

> 100°F* or per your facility protocol

Afebrile

no fever

Fatal temp

>108° F and <93.2° F

Hyperthermia

flushing, hot skin, chills

Hypothermia

pale, cold skin, clammy A

Taking rectal temp

• considered most accurate

• may be policy check rectal if oral above parameter

• may be used for unconscious clients

• contraindicated in diarrhea, colitis, or rectal cancer

• use lubricated disposable cover, insert 1,5” into rectum for 30-90 seconds

Taking axillary temperature

• least accurate

• adults when no other measurement possible (used often in newborns)

• disposable cover & place axillary space 1-3 minutes

Normal Parameters: Tympanic Temp:

96.4°- 100.4°F

Normal Parameters: Pulse:

60-100 BPM

Normal Parameters: Pulse:

12-20 BPM

Normal Parameters: Blood Pressure

• Low <90/60

• Normal 120/80

• Hypertension >140/90 mmHg (millimeters of Mercury)

Normal Parameters: O2

95-100%

Normal Parameters: Pain

0-10 (10 is worst)

Dysrhythmia & arrhythmia

irregular beating of the heart (may be life-threatening)

Tachycardia

(>100 bpm), exercise, emotion, low BP, dehydration, medications, heart failure, hemorrhage, fever

Bradycardia

(<60 bpm), conditioned athletes, brain injury, heart block, medications

Apical Pulse

• most accurate way to assess heart rate

• Stethoscope over the 5th intercostal space at midclavicular line

• Listen & count for 1 full minute

Apnea

episodic cessation of breathing

Bradypnea

slowed breathing

Eupnea

normal breathing

Tachypnea

rapid, elevated breathing

Hyperventilation

increased rate and depth/volume (extreme exercise, anxiety or Kussmaul’s with diabetic ketoacidosis)

Hypoventilation/ Respiratory Depression

decreased rate & depth (OD narcotics, anesthetics)

Cheyne-Strokes

alternating deep, rapid breaths and apnea (cognitive heart failure, stroke, CO poisoning, TBI, opiate overdoses, end of life)

Orthopnea

difficulty breathing when lying down

Factors that can affect pulse oximeter readings

fingernail polish or artificial nails, skin temperature, altitude, intravenous dyes, poor circulation, skin thickness, tobacco use, skin pigmentation

photoplethysmography

a graphical display of the signal overtime (pulse oximeter waveforms)

Oxygenation for COPD

• lower goal (88-92%)

• maintaining oxygen >92% in COPD patients will decrease their respiratory drive

Hypoxemia

low oxygen levels in the blood

Hypoxia

low oxygen levels in the tissues

Cyanosis

blue/grayish tinge in skin, lips

Blood pressure

determined by cardiac output & peripheral resistance

cardiac output

amount of blood your heart pumps per minute

peripheral resistance

resistance of blood vessels to flow of blood

hypertension (HTN)

high blood pressure

hypotension

low blood pressure

Systolic BP

(top number) highest pressure occurs with contraction of heart (first beat)

Diastolic BP

(bottom number) lowest pressure as heart relaxes (silence)

Why estimate POP

• avoid missing auscultatory gap

• abnormal silence can throw off the first sound you hear which is that systolic #

• Gap can be 10-50 mmHg long

• patients with HTN, older patients, patients with wide pulse pressure

• if you only inflate until you hear (rather than palpate) the pulse disappear, you you will underestimate the SBP

don’t take blood pressure

• no BP on side of mastectomy

• Arm with PICC or Central Line

• Fistula (dialysis patient)

Taking Oral Temperature

• wait 15 minutes after hot/cold drinks, gum, tobacco, (consumption)

• not for uncooperative or unconscious, or clients receiving O2

• disposable cover over thermometer

• place in rear sublingual pocket of mouth

• results 30-90 seconds, electronic faster

• document timely

Temporal temperature

• quickest/least invasive

• uncooperative/unconscious clients

• results instantaneous

Heart rate info

• pulse points: temporal, carotid, brachial, apical, radial, femoral, popliteal, pedal

• heart rate ordered with certain meds (beta blockers, calcium channel blockers, digoxin)

• apical most accurate, especially if HR irregular

Pain

body’s distress signal~ subjective symptom; comes from patient.

Client’s self report single best indicator of pain (pain is what they say it is)

Nociception

detection of pain

Transduction

Nervous system turns painful stimuli into impulses

Transmission

impulses travel to brain

Perception

brain recognizes, defines, and responds to brain N

Modulation

body attempts to alleviate pain by activating inhibitory response

Gate Control Theory

• spinal cord contains the nerve gate

• nociceptors are sending signals through the gate into the brain which helps us perceive pain

Acute pain

short, abrupt, intermittent, mild-severe, usually due to trauma, lasting < 3 months

Referred pain

away from origin, originating in one body part, pain felt elsewhere (heart attack felt in jaw)

Cancer pain

Malignancy; chronic severe and intractable → doesn’t solve pain

Chronic pain

lasting >3 months; may affect daily function

Neuropathic pain

nerve damage or malfunction, burning, tingling and or shooting pain → sciatic nerve pain

Intractable pain

difficult to treat, chronic pain that resists therapeutic interventions

Our role in pain assessment

• Assess and report to prescribers

• implement treatment/intervention strategies

• Documentation

• Emotional Support

• Reassess

Numeric Pain Scale (0-10)

patient verbally rates pain from 0 to 10 with 10 being the worst pain they can imagine

FLACC (Face, Legs, Activity, Cry, Consolability)

for nonverbal children (infants to about age 3)

Wong-Baker Faces Pain Scale

children ages 3-7 or adults with expressive barriers/language barriers~ stroke, brain dmg, autism

PAINAD (Pain Assessment in Advanced Dementia or brain damage)

• 5 categories with 0 - 2 points per category

• Higher points = more pain

• Highest score = 10

Numeric Pain Scale Numerical Rating

• 0 = no pain

• 1-3 = slight/mild

• 4-6 = Moderate pain

• 7-9 = severe

• 10 = worst possible pain

Pain Description and Assessment* PQRST

• P= Provocation/Palliation - What causes the pain and what makes it better?

• Q= Quality - What does the pain feel like? (aching, stabbing, burning)

• R= Region/Radiation- Where is the pain and does it move anywhere else?

• S= Severity- How severe is it (0-10) ?

• T= Timing- When did it start? Intermittent or constant? Is there a pattern?

Chronic Pain Characteristics and Approaches*

• Loss of control- regain control of one part of life at a time

• Decreased self-esteem- talk to support group, limit talking about pain with fam

• Difficulty setting life goals- control pain while resuming activity

• Change in Relationships/Family Role- family therapy/marriage therapy, assume leadership role

• Anger of family and friends- family therapy

• Decreased activity- alternative hobbies, activities, entertainment

• Decreased endurance- build up strength, keep moving

Special considerations for pain assessment

beliefs about the causes of pain, culture, gender expectations, traditional/nontraditional, yin/yang, hot/cold, spiritual and religious beliefs

Pain threshold

lowest point of pain perception

Pain tolerance

point in which pain is unendurable

Internal mechanisms

the body ha internal mechanisms that help control pain perception

Endorphins

• naturally occurring hormones that relieve pain, released during exercise or other physical stimulation, rapid decrease

• decreased endorphin production: opioids, excessive food consumption, depression, migraines, anxiety, fibromyalgia

Analgesics

• medications that relieve pain

• given when pain is experienced or anticipated

• when anticipated, such as after surgery or before physical therapy, it is best to administer on a regular schedule, before pain begins or spikes

Nonsteroidal anti-inflammatory drugs (NSAIDS)

aspirin, ibuprofen, naproxen, (mild to moderate pain)

Other nonopioid analgesics

Acetaminophen (mild pain)

Opioid analgesics

• Morphine, hydrocodone, oxycodone, fentanyl (moderate to severe)

• May be combined with another medication like acetaminophen

  • Ex: Norco 5mg/ 325 mg = hydrocodone 5mg + acetaminophen 325 mg

Adjuvant

enhances another drug’s effectiveness (antidepressants, anticonvulsants)

Non-pharmacologic pain relief

massage, acupuncture, guided imagery, deep breathing, exercise, heat/cold (heat requires order), TENS (transcutaneous electrical nerve stimulation)

Heat application*

• causes vasodilation, increasing blood flow, increases oxygen, nutrients, and blood cells delivered to specific body tissues and aids in waste removal from injured tissues

• application must be ordered by a provider and applied with utmost caution

• determine how much heat is safe and for how long

• Rationale for heat application in pain relief: local pain, stiffness, aching, particularly of muscles and joints~ increase circulation

Cold application*

• vasoconstriction (shrinkage of blood vessels), decreasing blood flow, slowing body’s metabolism and its demand for oxygen

• Rationale: pain/swelling following surgery or injury (tooth extraction, headache, muscle/joint injury, such as sprains), reduces inflammation, blocks pain receptors, diminishes muscle contraction and muscle spasms

Documentation of Pain

• Level of pain

• Description of Pain- PQRST

• Actions taken | Interventions- medications/ nonpharmacologic interventions

• Response to Interventions- document results of the interventions performed

Problems resulting from pain

depression, substance abuse, self- injurious behavior, social withdrawal, physical activity

Health Record

• Manual/electronic account of pt’s relationship with healthcare facility. “Charting”

• Used for: Effective communication, written evidence of accountability, legal/regulatory/financial requirements, data for research and education

Documentation & Malpractice

20% of medical malpractice cases involve at least one documentation failure

Narrative-Chronological (Documentation Format)

chronological order, must not chart out of order, good idea of what’s been happening overtime, time-consuming

Problem Oriented Medical Record (Documentation Format)

4 components

• Numbered Problem (at front of chart)

• Database (H+P, initial labs and diagnostic results)

• Plan of Care (a care plan for each problem)

• Progress Notes (SOAP)

SOAP Charting

S= subjective data, O= objective data, A= assessment, P= plan