Nurse 181 Exam 1

What are the parts of the admission process?

handoff report, admission assessment, med reconciliation, admission orders, pt learning assessment, valuables, advanced directives

What do we need to consider when transferring patients?

- nurse must accompany if they are going up a level of care

- what is the reason for transfer?

MD order is needed

-priorities before transfer

-med reconiliation

-document belongings

What do we need to consider for discharge?

- the reason for discharge

-assessment

-teaching

-belongings

When does planning for discharge begin?

on admission

5 rights of delegation in nursing

right task

right circumstance

right person

right communication

right supervision

tips for successful patient teaching

-pt & family need to be active participants

-begin education upon admission

-build upon prior concepts

-use multiple methods of learning

-do not assume pt knows about disease/condition

-minimized distraction

-timing is everything

-present info in pt's primary language

What are the 3 goals of patient education?

1) maintenance & promotion of health and illness prevention

2) restoration of health

3) coping with impaired functions

What are the 3 domains of learning?

cognitive, affective, psychomotor

cognitive learning

thinking, reasoning, and mental problem solving

affective learning

feelings & development of attitudes/beliefs

psychomotor learning

incorporation of both mental skills and physical movements, motor skills

What is the teach-back method?

assist nurses w/ ensuring you have taught pt adequately

-shown to reduce hospital admissions & improves pt satisfaction

What are the 4 stages of teach back?

1) explaining

2) assessing

3) clarifying

4) understanding

What is health literacy?

the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

What is health literacy comprised of?

-basic reading skills

-understand oral communication

-basic math skills

-ability to navigate health system on a basic level

-ability to communicate with health care providers

What percentage of the population has basic/low health literacy levels?

43%

What are some things that low health literacy is associated with?

increased hospitalizations & increased health care costs

-worse health outcomes & increased mortality

-difficulty understanding med instructions/adhering to treatment

-inability to implement appropriate self care

How much of our lives do we spend sleeping?

1/3

Why is sleep important?

for brain function & body restoration

What are the stages of sleep?

NREM-1, NREM-2, NREM-3, REM

NREM-1

falling asleep

-eye movements slow

-overall loss in awareness, thought, and responsiveness

-easily awakened

NREM-2

deeper than stage 1

- EEG: high voltage slow-waves

NREM-3

deeper sleep than stage 2

-EEG: more high voltage slow-waves appear

NREM-4

deepest state of sleep

-EEG: a lot of high voltage slow-waves

REM

-muscles cannot move

-most people awakened in REM sleep report dreaming

What are some factors that interfere with sleep?

age, sex, pain, pre-hospital function/health, sleeping disorders, psychological conditions, noise, equipment, patient care, meds, alcohol, stress

Short term consequences of inadequate sleep

-drowsiness

-decrease reaction time

-difficulty concentrating

-memory problems

-anxiety, depression

-increase in stress levels

Long term consequences of inadequate sleep

-reduced pain threshold

-decreased immune function

-decreased functional status

-impaired wound healing

-development of metabolic diseases

-cardiovascular disease

What are some interventions to promote sleep?

-decrease noise

-room temp

-lighting

-pain management

-maintain regular bedtime & wake time

-medications

Insomnia

recurring problems in falling or staying asleep

Obstructive sleep apnea

pauses in breathing/shallow breaths while asleep

restless leg syndrome

uncomfortable sensations in legs causing movement and loss of sleep

narcolepsy

A sleep disorder characterized by uncontrollable sleep attacks

What is the #1 reason people seek medical care?

pain

What patient's are at risk for untreated pain?

-cognitively impaired

-critically ill

-comatose/actively dying

-non-english speakers

-pt's with history of substance abuse

How often do we assess pain?

every 4 hrs with vital signs

OLDCART

O- onset

L- location

D- duration

C- characteristics

A- aggravating factors

R- relieving factors

T- treatment

PQRST

P-provocative/palliative

Q-quality

R-region/radiation

S-severity

T-timing

pain scales: numeric

0-10

Pain Scales: Wong-Baker FACES Pain Rating Scale

often used for children

Pain scales: FLACC

face, legs, activity, cry, consolability

Critical Care Pain Observation Tool (CPOT)

Adults who are sedated and nonresponsive

PAINAD scale

Patients whose dementia is so advanced that they cannot verbally communicate

What are some signs/symptoms of pain?

-facial expressions

-verbalization/vocalization

-body movements

-change in interpersonal interactions

-change in activities or routines

-mental status changes

What can unrelieved/untreated pain cause?

-prolonged stress response

-increase in HR, BP, & O2

-decrease in GI motility

-decreased immune response which delays healing

-increase risk of developing chronic pain

-anxiety, depression, hopelessness

-increases LOS

What are the different types of pain? simple classification

acute, cancer, chronic/nonmalignant pain

What are the different types of pain? pathophysiology

nocicpetive, neuropathic, combo of both

What is nociceptive pain?

damage to somatic or visceral tissue

-normal pain processing event

What is neuropathic pain?

- chronic pain, abnormal pain process along the nerve pathways

What is acute pain?

sudden onset, usually subsides once treated

-usually has a defined cause

-biological warning signs: increased HR, BP, RR & sweating

What is chronic pain?

-usually lasts longer than 3 months

-no biological warnings

-cause may or may not be known

-impacts ADLs/QOL

-body adapts to pain

-2x suicide rates in pt's w/ chronic pain

Nociceptive pain: somatic

In bones, joints, muscles, skin, or connective tissue

-aching/throbbing

-well localized

Nociceptive pain: visceral

-arises from organs

-tumor involvement

-aching

-intermitten cramping

-poorly localized

Neuropathic pain presents as...

burning, shooting, pins & needles, tingling

Neuropathic pain: CNS

-phantom pain

-burning below level of spinal injury

Neuropathic pain: PNS

-diabetic neuropathy

- Guillain-Barre' syndrome

What are some rules for the pharmacological treatment of pain?

-start oral meds first if we can

-start slow & low doses

Acute pain meds: mild pain (1-3)

NSAID/tylenol

Acute pain meds: moderate pain (4-6)

hydrocodone or oxycodone w/NSAIDs

Acute pain meds: severe pain (7-10)

hydromorphone, morphine, or fentanyl

Meds for chronic/nonmalignant pain:

non-opiod: NSAID, acetaminophen

breakthrough pain: longer acting or immediate release opioids

Non-opioids: NSAIDs & acetaminophen

- analgesic and anti-inflammatory properties

- given oral or IV

-side effects: gastric toxicity & ulcerations

-use cautiously in > 60 in age, PUD, CUD, and impaired renal function

Daily totals for ibuprofen

no more than 2400-3000 mg daily

daily total for aspirin

no more than 6 g daily

Non-opioids: acetaminophen

-analgesic & antipyretic properties

-no anti-inflammatory effect

-does not interfere with platelet function

- does not produce GI problems

-can cause liver problems: hepatotoxicity

-used for mild & moderate pain in osteoarthritis

Daily totals for acetaminophen

no more than 4 grams daily

Opioids

-can be natural or synthetic

-block the release of neurotransmitters in the brain & spinal cord

-used to treat moderate/severe pain

-first line of drug to treat nociceptive pain

-bind to receptors in the CNS, peripheral nerves & immune system

Examples of opioids

hydrocodone, morphine, fentanyl, and oxycodone

Morphine sulfate

- drug of choice for relieving severe pain

-for short term & ICU's

-binds to receptors in the spinal cord and brain

morphine sulfate: OPD

onset: 5-10 minutes

peak: 20 minutes

duration: 1-3 hours

Hydromorpone (Dilaudid): IV starting dose

1-3 mg

Hydromorpone (Dilaudid): OPD

onset: 5 mins

peak: 10-20 minutes

duration: 3-4 hrs

Fentanyl: OPD

onset: 2-5 minutes

duration: 15 minutes to 1 hr

Important to know for fentanyl patches

do NOT apply heat

signs of opioid intoxication

- drooping eyelids

-head nodding

-scratching/itching

-constricted pupils

-decreased RR or BP

Signs of opioid overdose

-difficulty to arouse/drowsiness

-shallow breathing; decreased, snoring sounds

-mental confusion

-nausea

-constipation

- pin-point pupils

-hypotension

Normal/moderate opioid withdrawal symptoms

-anxiety

-restlessness

-irritability

-nausea/vomitting

-muscle aches

-diarrhea

-fever

-insomnia

severe opioid withdrawal symptoms

-tachycardia

-increased BP

-yawning

-dilated pupils

-runny nose, sneezing, tearing up

-goosebumps/shivers

-abdominal cramps

-agitation

What is naloxone (narcan)?

A narcotic antagonist that reverses the effects of opioids

-IV, IM, SubQ, or nasal spray

-when administering elevate HOB, turn pt on side because can induce vomiting

How fast does narcan work?

30 seconds to 2 minutes

What can administration of narcan cause?

vomiting, nausea

- sweating

-tachycardia, increased BP

-seizures

-arrhythmia: V-tach, V-fib, cardiac arrest

What do anticonvulsants do?

- reduce neurotransmitter release

-are helpful for neuropathic pain

-helpful for shooting/stabbing pain, sleep & anxiety

-Gabapentin & pregabalin are first line of drugs

-used to treat post-op pain

If someone with kidney disease is on an anticonvulsant what must we do?

-lower dose

-monitor BUN, creatinine

-monitor lower extremity edema

-monitor for sedation, dizziness, and weight gain

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

decreases serotonin and norepinephrine reuptake in the brain & spinal cord

- lower doses are given for pain compared to depression

-if discontinued: requires weaning off

-pran & -ine

Side effects of SNRIs

nausea, headache, sedation insomnia, weight gain, impaired memory & tremors

Tricyclic antidepressants are used for

neuropathic pain, sleep, depression, migraines, and anxiety

-TCAs have dual inhibition effects on norepinephrine & serotonin reuptake

Adverse effects of TCAs

QTc prolongation, serotonin syndrome, overdose potential, avoid in CAD

Side effects of TCAs

orthostatic hypotension, dry mouth, foggy brain, constipation

What should we teach about when giving meds for pain management?

- side effects

- risks & benefits

-nonpharmacological options

Nursing care w/ pain management

- know 24-hr gram limit

-lab values

-know reassessment time frames

What is marijuana used for?

to treat anxiety, seizures, muscle aches, mild-moderate pain

Cannabis medical use is for:

-chronic pain

-M.S.

-fibromyalgia

-sleep apnea

-chemotherapy (nausea/vomiting)

What are some non-pharmacological treatments?

-psychosocial interventions (CBT/support groups)

-exercises

-PT/OT

-music

-distraction

-cryotherapy

-acupuncture, massage & Tai Chi

Hypertension effects how many U.S. adults?

1 in 3 (80 million americans)

-11 million aren't aware that they have it

Ages 35-44 hypertension effects ___ in ____ women:

1, 5: after menopause numbers increase for women

Ages 35-44 hypertension effects ___ in ____ men:

1, 4

- usually diagnosed at younger ages compared to women

What can uncontrolled high BP lead to during midlife?

-higher risk for dementia

-kidney failure

-heart failure

-stroke

Who is at greatest risk for hypertension?

african americans due to higher rates of obesity, diabetes & stroke

What is blood pressure?

the amount of force caused by blood pushing against the arteries

What are the 4 factors that influence BP?

cardiac output, blood volume, peripheral resistance, and blood viscocity