NUR-230 FINAL

all i know is pain

health database is formed from

subjective and objective data plus patient’s record and lab studies

steps of the nursing process

assessment

diagnosis

outcome identification

planning

implementation

evaluation

Four types of data

complete total health database

episodic or problem-centered database

follow-up database

emergency database

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Nursing diagnosis-how to write one

problem/diagnostic label related to etiology/ related factors as evidenced by signs/symptoms

effective care

positive outcomes and satisfaction for patient

respectful care

considers values, preferences, and expressed needs for patient

cultural and linguistic competence

congruent behaviors, attitudes, and policies that come together in a system among professionals that enables work in cross-cultural situations

steps to cultural competency

culturally sensitive

culturally appropriate

culturally competent

cultural care

HIPAA rules say:

you cant talk about patients outside of office with anyone

clinicians should only access info needed for job/clinical experience

need patients to give permission before we can give info to others

keep medical records secure

HIPAA rules require us to:

treat all things we learn confidential

provide more control to patients

punish those who misuse patient information

HIPAA rules were invented to

balance between improving flow of info while protecting privacy of patients

W/ HIPAA, the pt has the right to

request access to health info

request to amend their health info

request restrictions to info sharing

request accountability of disclosures

SOAP

Subjective, objective, assessment, plan

What is the health interview?

subjective data collection

patient perception of health

first step in therapeutic relationship

Successful interview characteristics

gather complete and accurate data about health state

establish rapport and trust

teach person about health state

build support to continue therapeutic relationship

Communication internal factors

liking others

empathy

ability to listen

Communication external factors

ensure privacy

refuse interruptions

physical environment

dress

note-taking may be unavoidable

tape and video recording

When to use open-ended questions?

to begin interview

introduce new section of questions

whenever patient introduces a new topic

When to use closed or direct questions?

after opening narrative to fill in details

when you need specific facts about PMH or ROS

to move interview along

10 traps of interviewing

providing false assurance

giving unwanted advice

using authority

using avoidance language

engaging in distancing

using professional jargon

using leading or biased questions

talking too much

interrupting

using “why” questions

elements of interview process

nonverbal skills

physical appearance

posture

gestures

facial expression

eye contact

voice

touch

closing the interview

5 types of nonverbal behaviors

vocal cues

action cues

object cues

personal space

touch

two pathways of pain

nociceptive and neuropathic

nociceptors

specialized nerve endings designed to detect painful sensations

Ao fibers

myelinated

larger in diameter

rapid

localized, short term, sharp

C fibers

unmyelinated

slower signal

diffuse and aching

persist after initial injury

nociceptors fibers pain signals…

cross over to other side of spinal cord and ascend to brain by anterolateral spinothalmic tract

phases of nociception

transduction

transmission

perception

modulation

when does nociceptive pain develop

when functioning and intact nerve fibers in the periphery and CNS are stimulated

neuropathic pain

indicates a type of pain that does not adhere to typical phases in inherent in nociceptive pain

what is the proposed mechanism of neuropathic pain

spontaneous and repetitive firing of nerve fibers, almost seizure in activity

visceral pain

originates from larger interior organs

direct injury to organ or from stretching of organ from tumor

deep somatic pain

comes from blood vessels, joints, tendons, muscles, bone

described as aching or throbbing

cutaneous pain

derived from skin surface and subcutaneous tissues

sharp, burning sensation and superficial

referred pain

felt at particular site but originates from another location

both sites are innervated by the same spinal nerve and it is difficult for brain to differentiate point of origin

chronic pain

6 months or longer

outlasts protective function

malignant pain often parallels pathology created by tumor cells

pain induced by tissue necrosis or stretching of an organ

chronic nonmalignant pain is often associated with ms conditions

breakthrough pain

transient spike in pain level with moderate to severe intensity in an otherwise controlled pain syndrome

women are ____ x more likely to experience migraines during childbearing years and ___ x more likely to have fibromyalgia

2-3

6

Pain is..

defined as an unpleasant sensory and emotional experience

associated with actual or potential tissue damage or described in terms of such damage

gold standard of pain assessment

subjective report

initial pain assessment questions

do you have pain

where

when

what does it feel like

how much do you have now

what makes it worse

how does it limit function

how do you react

what does it mean to you

look for associated symptoms

types of pain assessment tools

initial pain assessment

brief pain inventory

short-form mcgill pain questionnaire

PQRSTU

provocation/palliation

quality/quantity

region/radiation

severity scale

timing

rating scale introduced at 4-5 years

faces pain-scale-revised (6 drawings)

for pain, look for

swelling

interrupting in skin integrity

altered function

misalignment

erythema

objective data-pain

joints: note size, contour, and circumference, check active or passive ROM

muscle and skin: inspect tissues, swelling, and masses/deformity

abdomen: contour and symmetry, palpate for guarding and organ size, note areas of referred pain

acute pain behaviors

autonomic responses

guarding, grimacing

vocalizations

diaphoresis

change in vitals

chronic pain behaviors

more variability than acute pain behaviors

bracing, rubbing

diminished activity

sighing

change in appetite

anger, frustration, depression

CRIES scale

measures posted pain in preterm and term neonates

3 point scale

crying, req 02, increased vitals, expression, sleeplessness

FLACC scale

nonverbal tool for infants and children up to age 3

facial expression, leg movement, activist level, cry, consolability

PAINAD scale

for patients with dementia

breathing, vocalization, facial expression, body language, consolability

score of 4 or more= need treatment

health history sequence

biographical data

source of history

reason for seeking care

HPI

PMH

FH

ROS

ADLS

additional questions for new immigrants

biographical data

spiritual resource and religion

past health

health perception

nutrition

CAGE test

cut down your drinking?

annoyed by criticism of your drinking?

guilty about your drinking?

eyeopener?

HEEADSSS

home environment

education/employment

eating

activities

drugs

sexuality

suicide and depression

safety

Older adult PMH

general health in past 5 years

accidents or injuries

serious chronic illnesses

hospitalizations and operations

last examination

obstetric status

Older adult: medication profile

current mediations

some may take a large amount prescribed by diff providers

may not know name or purpose

may decrease dose due to cost

travel may be an issue

may use OTC

may share with neighbors or friends

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water is ____ of total body weight

45-55%

assessment of fluid in body (3)

bp

edema

strength of pulses

recommended intake for men and women

2700mL for women

3500mL for men

__% from food/metabolism of food

20, thus about 2L per day intake required

fluid intake is regulated by…

thirst

change in plasma osmolarity

hypothalamus

5ml=

1 tsp

15 mL=

1 tbs

30 mL=

1 oz

Fluid output in mL

Urine: 1500mL/day

Skin: perspiration

lungs: exhalation

feces: 100-200mL/day

wounds

hormonal regulation

ADH

Renin-angiotensin system

aldosterone

thyroid hormone

brain natriuretic peptide

Sodium

ECF

regulates fluid volume

kidney reabsorbs and H20 and K follows

2300 mg /day

Potassium

ICF

Muscle contraction and cardiac conduction

kidneys eliminate

4700mg/D

Calcium

bone health, neuromuscular function, cardiac function

magnesium

ICF

bone, many cellular functions

alcoholism leads to low levels

chloride

ecf

bound to other ions

assessment of electrolyte balance

via serum testing

subjective findings for hypovolemia

dizzy/lightheaded/fainting

fatigue

objective findings for hypovolemia

dry skin, dry mucous membranes-cracking

non-elastic skin turgor/tenting

decreased urine output and hypotension

tachycardia

rise in temperature

poor cap refill

weight loss

orthostatic BP steps

lie down 5 mins

sit or stand 1 min

sit or stand 3 mins

orthostasis

systolic down by 20+ points

diastolic down by 10+ points

pulse up by 30+ points

objective findings for hypervolemia

elevated BP and pulse

pale, cool skin

edema/ascites

crackles

weight gain

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On assessment of a patient with acute renal \n failure, the nurse finds the following: \n distended neck veins, cool and pale skin, and \n crackles in the lungs. The nurse should suspect \n the patient is experiencing

hypervolemia

general survey is a study of

the whole person

covers general health state and any obvious physical characteristics

4 areas to consider during general survey

physical appearance

body structure

mobility

behavior

physical appearance:

age

sex

LOC

skin color

facial features

NAD

body structure:

stature

nutrition

symmetry

posture

position

body build, contour

obvious physical deformities

normal body build

arm span (fingertip to finger tip equals height)

body length from down to pubis roughly equal to length from pubis to sole

mobility:

gait: base is as wide as shoulder width

foot placement

ROM

no involuntary movement

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behavior:

facial expression

mood anf affect

speech

dress

personal hygiene

measuring weight

when sequence of repeated weights is necessary, aim for approximately same time of day and same type of clothing worn each time

BMI is….

practical marker of optimal weight for height and an indicator of obesity or protein-calorie malnutrition

cellular metabolism requires a stable core, or deep body temp of a mean of

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37\.2 C (99 F)

regulated in hypothalamus

normal temp is influenced by:

diurnal cycle of 1 F-1.5 F

menstruation cycle: 0.5F-1 F

exercise

age

mean temperature for older adults

36\.2 C (97.2F)

Normal temp

35\.8C-37.3 C (96.4 F-99.1F)

Rectal temperatures

measures 0.4-0.5 C (0.7-1 F) higher

shake a mercury glass thermometer down to

35\.5 C (96 F)

Tympanic membrane thermometer

tympanic membrane shares same vascular supply that perfuses hypothalamus (internal carotid artery)

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gently place covered probe tip in person’s ear \\n canal

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good for unconscious or critical ill, in labor

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stroke volume

amount of blood every heart beat pumps into aorta

70 mL in adult

assess pulse for

rate

rhythm

force

elasticity

sinus arrhythmia

one irregularity commonly found in children and young adults

heart rate varies with respiratory cycle, speeding up at peak of inspiration and slowing to normal with expiration

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force of pulse is:

strength of heart’s stroke volume