Exam 1 N342

ED

• Entry point to acute care

• Urgent or life threatening

Med-Surg

• A little longer stay than ED

ICU

• Critical & highly specialized care

PACU

• Post surgery before going to Med surg

• Post anesthesia

Rehabilitation

• if not healing correctly from med-surg

CMS Required Screening

• Interpersonal safety

• Food insecurity

• Housing instability

• Transportation needs

• Utility difficulties

Equity

• custom tools that identify and address inequality

Delirium

• Acute state of confusion

• Fluctuating onset (comes & goes)

• Often reversible (focus is to find underlying problem

• Treatment

  • Reorientate

  • Mimic schedules

  • NO antipsychotic meds

  • Treat underlying issue ex: UTI

Restraint

• Must be prescribed by a healthcare provider

• Check patient ever 30-60 minutes & release ____ every 1-2 hrs

• Chemical

  • Antipsychotics

  • Anti anxiety drugs

  • Antidepressants

  • Sedative-hypnotics

Morse Fall Scale

• Fall risk assessment

SBAR

• brief statement (situation)

• Recent procedures, etc. (background)

• Heard crackles, etc. (assessment)

• Send home with etc. (recommendation)

Care Coordination and Transition Management

• organization and communication about patient care

• Takes place between two or more healthcare team members

• Care transition

• Transition management

Nocioceptive

• Normal pain

• Tissue damage/inflammation

• Expected

Neuropathic

• Abnormal

• Can occur with no tissue damage or inflammation

• Damage to nervous system

Acute pain

• Acts as warning sign

• Activation of sympathetic nervous system

• “Fight or flight” reactions

• Absence of response does not mean absence of pain

Chronic pain

• Lasts or recurs fo more than 3 months

• Gradual onset

• Character and quality often change over time

• Serves no biological purpose

• Can result in emotional, financial, and relationship burdens as wlell as depression/hopelessness

Comprehensive Assesment Recognizing Cues

• Onset

• Location

• Duration

• Characteristics/quality

• Aggravating factors

• Relieving factors

Comprehensive assessment: recognize cues

• Timing

• Severity/ intensity

• Effect of pain on function and quality of life

• Comfort-function (pain intensity) it comes- Pain goal

Assessment Challenges

• Patients who can’t self report pain are at higher risk for undertreated pain

Drug Therapy for Pain

• Multimodel analgesia

  • Routes of admin

  • Around the clock dosing

• Patient-controlled analgesia (PCA)

• Intraspinal analgesia

Key principles of opioid administration

• Titration

• Dependence, tolerance, addiction

• Opioid naive

• Opioid tolerant

• Equianalegsia

• Drug formulary

Adverse Effects of Opioid Analgesics

• Respiratory depression

• Constipation

• Nausea/vomiting

• Pruritis

• Sedation

Opioid Toxicity/ Overdose

• Reverse the effects

• Narcan (Naloxone)

  • Reverses respiratory depression, unresponsiveness, and coma

  • Monitor patient closely after administration

  • May need repeated doses

PQRSTU

• Provocative or Palliative

• Quality

• Understanding

• Region/radiating

• Timing

Non-Opioid Analgesics

• Acetaminophen

• NSAIDS

Opioid Analgesics

• Morphine

• Fentanyl

• Hydromorphone

Adjuvant (analgesic)

• Anticonvulsants

• Antidepressants

Nonpharmacologic management

• PT

• OT

• Aqua therapy

• Functional restoration

• Acupuncture

• Low impact exercise

• Cutaneous (skin) stimulation

• Cryotherapy (cold therapy)

• Thermal therapy (Heat)

• Spinal cord stimulation (invasive)

Home care management for pain

• Prevent fatigue (which exacerbates pain)

• Home infusion therapy programs

Self management education for pain

• Analgesic regimen

• Family support

Health care resources

• Referrals

  • Home health

  • Hospice

  • Pain specialist

5%

• Loss of ___ of body weight in a month should be checked out

10%

• Loss of ___ of the body weight in 6 months should e checked out

Protein-energy undernutrition (PEU) aka Protein-calorie malnutrition (PCM)

• Acute PEU (injury which prevents eating) or Chronic PEU (disorder prevents ex: cancer, kidney diseases)

• Marasmus

• Kwashiorkor

• Starvation

Anorexia Nervosa

• Doesn’t eat because scared to get fat

Body dysmorphic disorder

• Obsessed with looking a certain way

Bulimia Nervosa

• Binge eating then purging

Binge eating disorder

• Eating so much you feel sick

Marasmus

• Calorie malnutrition

• Body fat & protein wasting

Kwashiorkor

• Lack of protein but with adequate calories

  • Beer belly

Physical risk factors for undernutrition

• Chronic conditions/illnesses

• Constipation

• Decreased appetite

• Dentition

• Drugs

• Dry mouth

• “Failure to thrive”

• Impaired eyesight

• Pain that is acute or persistent

• Weight loss

Psychosocial risk factors for undernutrition

• Ability to prepare meals

• Decrease in enjoyment of meals

• Depression

• Income

• Loneliness

• Proximity to food sources

• Transportation access

Physical assessment and recognizing cues of undernutrition

• Assess hair, eyes, oral cavity, nails, skin, musculoskeletal, neurologic systems

• 3 day calorie intake: done by RDN

• Anthropometric measurements

• Food & fluid intake

S&S of undernutrition

• loss of hair

• Dryness and vision blindness

• GI issues & swollen gums

• Dry skin

• Subq fat loss, bone pain, edema

• Anemia

• Disorientation

• Dysrhythmias

First step of undernutrition .

• Meal management

• Change consistency of meal

Second step of undernutrition

• Nutrition supplements

• Ex: ensure

Third step of undernutrition

• Drug therapy

• Multivitamins

• Zinc

• Iron preparations (good for preventing anemia)

If H&H increases it worked

Total enteral nutrition (TEN)

• Last resort from multivitamins, ensure, etc.

• Used if patient can’t achieve nutrition via oral intake

  • Can eat but not maintain adequate nutrition

  • Permanent neuromuscular impairment

  • Can’t eat bc of condition

Nasoenteric tube

• Used short term (<4 weeks)

• Nasogastric tube (NG)

• Nasoduodenal tube (NDT)

• Nasojejunal tube (NJT)

Nasogastric tube (NG)

• Feeding

• Meds

• Pull things out (decompression)

  • Ex: bowel obstruction

Nasoduodenal tube (ND)

• Aspiration risk is high

• Gastric emptying issue

Nasojejunal tube (NJT)

• Pancreatitis

• High gag reflex

• High aspiration risk

Enterostomal feeding tubes

• Used long term

• Gastrostomy performed

• Percutaneous endoscopic gastrostomy (PEG)

• Dual-access gastrostomy-jejunostomy (PEG/J) placed

  • Jejunal port - to feed

  • Gastric port - to decompress

TEN care & maintenance

• Placement verified by X-Ray or KUB

• Secure

  • Bandage - short term

  • Stitch - long term

• Residual checks (check the remaining in the tube before feeding

• >30 degrees while and 1 hr after feeding

Complications of TEN

• Priority is always safety

• Obstructed tube is the most common problem

• Tube misplacement, dislodgement

  • Remove any tube expected to being dislodged

  • Flush tube 30 mL before & after ever 4 hrs

  • Order x-ray

  • Will feel resistance/flush & check residual to check dislodgement

Complications of TEN

• Abdominal distention and nausea/vomiting

  • Caused by over feeding

• Fluid & electrolyte imbalance

  • Fluid overload (increase in BP/pulse & crackles in lungs

  • Diarrhea & dehydration can occur

  • Hyperkalemia

  • Hyponatremia

Refeeding syndrome

• Life threatening complication related to extreme fluid & electrolyte imbalance after a period of low fluid & electrolyte

• Very slow reintroduction of nutrition electrolytes

Failure to thrive

• Diagnosed if have 3/5

  • Unintentional weight loss

  • Bradykinesia

  • Weakness

  • Low activity level

  • Exhaustion

• Monitor for complications

  • Dehydration

  • Electrolyte imbalance

  • Cognitive changes