Lecture Review Flashcards

Exam Information

• The exam will include approximately 1-2 points from each lecture prior to the exam (Modules 1-7):

  • Career Planning
  • Whole Person Care in Health/Illness
  • Stress & Stressors
  • Nursing Process (I & II)
  • Professional HCP Communication
  • Spiritual Care
  • Grief and Loss
  • Psych. & Develop. Care
  • Sexuality
  • Cultural Care

• The exam will include approximately 1-2 points from each skills category covered prior to the exam (Modules 1-3):

  • Capillary blood glucose monitoring
  • Medication administration: PO
  • Medication administration: Parenteral
  • Medication administration: Transdermal/Topical
  • Sequential compression devices

• The exam will include approximately 1-2 points from each skills category covered prior to the exam (Modules 4-7):

  • Bladder scanning
  • Incentive Spirometry
  • Basic Oxygen therapy
  • Specimen collection
  • Enemas

• The exam will include approximately 1-2 points from ATI “Nurse’s Touch Professional Communication”

Final Exam Information

• The final exam will reflect approximately 8-11 points from each lecture prior to the final exam (Modules 8-10):

  • Physiological Integrity
  • Care of Older Adult
  • Wounds & Skin Integrity
  • Pain Management
  • O2 & Thermoregulation

• The final exam will include approximately 2-4 points from each skills category covered prior to the exam (Modules 4-7):

  • Physical Restraints

Physiological Integrity

• Learning Outcomes:
  1. Discuss what would be assessed when considering the physiological aspects of a client.
  2. Use the nursing process to plan care for a client who has dysfunctional human responses or would like to achieve a higher level of wellness in each of the following areas:
     a) mobility,
     b) sleep,
     c) nutrition,
     d) urinary elimination,
     e) fecal elimination,
     f) sensory function.
  3. Describe common problems seen in secondary or post-operative clients and discuss how prevention or proactive interventions could be implemented.

Integrity Definition

• The state of being whole or undivided.

Physiological Aspect

• Relates to the body system and normal, healthy body functions.

Common Areas for Higher Wellness

• Mobility/Activity
• Sleep/Rest
• Nutrition/GI Function
• Urinary Elimination
• Fecal Elimination
• Sensory Function

Common Concerns & Basic Nursing Care

• Reviewing common areas to identify how to apply basic nursing care; applying the nursing process to common concerns to strive towards the preservation of physiological integrity.

Mobility/Activity

• Assessment:
  • Which assessment should be included in the analysis of a client’s ADL completion?
  • a. Ability to bathe and dress
  • b. Intake and output
  • c. Range of joint motion
  • d. Vital signs

Decreased Activity Tolerance

• If tolerance is the type and amount of exercise or daily living activities an individual is able to perform without experiencing adverse effects, then…?

Respiratory Problems in Sedentary or Post-Op Patients

• Pneumonia
• Atelectasis
• Pulmonary Embolism

Circulation Concerns

• Hemorrhage
• Hypovolemic Shock
• Thrombophlebitis
• Wound Infection

Inactivity & Depression

• Do people who are Inactive become Depressed?

Rest/Sleep

• Rest: implies a decreased state of activity with the consequent feeling of calmness, relaxation without emotional stress, and freedom from anxiety.
• Sleep: is an altered state of consciousness in which the individual’s perception of and reaction to the environment is decreased.

Lack of Rest/Sleep

• What are some human responses you would expect if a client has a lack of rest/sleep?
• What is insomnia?

Nutrition

• Risk factors for nutrition problems.
• Concerns with Nausea/Vomiting/Diarrhea.
• Poor wound healing as a result of Poor Nutrition?

Urinary Elimination

• Assessment questions/factors to ask about:
  • Medications
  • Fluid intake vs output
  • Description of urine & any changes
• Normal & abnormal for urine.
• Urinary retention.
• Urinary Tract Infection (UTI).

Fecal Elimination

• Normal fecal elimination.
• Questions to ask the client.
• Factors influencing fecal elimination:
  • Developmental stage
  • Daily patterns
  • Fluid/food intake
  • Level of activity
  • Lifestyle
  • Emotional stress
  • Medications
  • Procedures
  • Pathologic processes
• Constipation.
• Incontinence of fecal matter.

Sensory Function Problems

Visual Problems:

• Examples: Cataracts, glaucoma, blindness

Hearing Problems:

• Conduct hearing loss
• Sensory-Neural Hearing Impairment
  • Example: Presbycusis

Goals for Sensory Perception Disturbances

• Prevent injury
• Maintain function of existing senses
• Effective communication
• Perform ADLs
• Reduce isolation
• Prevent sensory deprivation/overload

Practice Questions

1. Five minutes after the client’s first postoperative exercise, the client’s vital signs have not yet returned to baseline. Which nursing diagnosis is most appropriate?
   • A. Activity Intolerance
   • B. Impaired Physical Mobility
   • C. Risk for Activity Intolerance
   • D. Risk for Disuse Syndrome
2. It is now midnight, and your male client is still unable to fall asleep. What should the nurse do to help him sleep?
   • a. Bring him a glass of iced tea.
   • b. Ensure that his bed linen is wrinkle-free and offer him a back massage.
   • c. Open the window or turn down the thermostat to bring the room temperature down to below 50 degrees F.
   • d. Suggest that he walk up and down the hall until he becomes tired enough to sleep.
3. An older Asian client has mild dysphasia (e.g., difficulty swallowing) from a recent stroke. Which one of the following considerations should the nurse incorporate into the dietary plan?
   • a. Eliminate the beer usually every evening.
   • b. Have at least one serving of thick dairy (e.g., pudding, ice cream, etc.) per meal.
   • c. Include as many of the client’s favorite foods as possible
   • d. Increase the calories from lipids to 40%
4. Which one of the following characteristics would be congruent with normal urine?
   • a. It appears transparent
   • b. It contains mucus
   • c. It has a musty odor
   • d. It is dark amber in color
5. The stools of a client experiencing upper GI tract bleeding will usually appear what color?
   • a. Black
   • b. Bright red
   • c. Clay-colored
   • d. Greenish
6. A client with impaired vision is admitted to the hospital. Which interventions are most appropriate to meet the clients needs? Select all that apply?
   • a. Decreased background noise before speaking
   • b. Explain the sounds in the environment
   • c. Identify yourself by name
   • d. Keep your voice at the same level throughout the conversation
   • e. Stay in the client’s field of vision

Care of the Older Adult

• Learning Outcomes:
  • Explore your attitudes and knowledge regarding older adults, comparing reality of characteristics and care settings with past understanding.
  • Describe developmental tasks of the older adult.
  • Describe psychosocial changes to which the older adult adjusts during the aging process.
  • Describe usual physiological changes that occur during older adulthood.
  • Explain examples of interventions that could promote health in older adults.

Definitions of the Older Adult

• Young-old = 60 years to 74 years (ages may vary depending on source)
• Middle-old = 75 to 84 years
• Old-old = 85+ years
• Centenarians = Older than 100
• Gerontology – study of aging and older adults (Taylor et al., 2019, p. 585)
• Geriatrics – medical care of older adults

Attitudes Towards Aging

• Ageism
• Myths and stereotypes
• Culture – How does your culture view the older adult?

Care Settings

• Acute care facilities
• Long-term care facilities
  1. Assisted living – own apartment, but some help with ADLs; facility provides meals, weekly activities, and socialization
  2. Intermediate – additional assistance, 24 hours nursing oversight to protect the client from injury and increase quality of life; no longer independent
  3. Skilled nursing facility (SNF) – higher level of nursing care: tube feedings, IV therapy, chronic wound therapy, mechanical ventilators; physical/occupational/speech therapy
  4. Alzheimer’s Disease/memory care units– specialized knowledge and help family members understand and cope with the disease process
• Hospice - provide client with pain management and psychosocial/spiritual care through the dying process
• Gerontological Rehabilitation Nursing – combines expertise in gerontological nursing with rehabilitation concepts and practice; more intensive therapy than SNF

Community

1. Home health – for clients who are homebound and unable to leave home without a considerable amount of effort (Medicare)
2. Nurse-run ambulatory care clinics – management of chronic illness; nurses follow up with telephone contacts or home visits
3. Adult day services centers – focus is on social activities and health care; level of nursing care may vary

Normal, Common Physiological Changes

Integumentary

• Increased skin dryness, pallor, and fragility
• Progressive wrinkling and sagging of the skin
• Decreased perspiration
• Thinning and graying of scalp, pubic, and axillary hair
• Slower nail growth and increased thickening with ridges
• Senile lentigines, senile/seborrheic keratosis, senile/ actinic purpura

Nursing interventions

• Maintain healthy skin
• Avoid sun damage
• Prevent skin injury

Neuromuscular

• Decreased speed and power of skeletal muscle contractions
• Loss of height and bone mass
• Sarcopenia
• Joint stiffness
• Impaired balance
• Greater difficulty in complex learning and abstraction
• Changes in cognitive ability and memory

Nursing interventions

• Assess function and identify fall risk factors
• Provide information about risk factors for osteoporosis
• Teach about importance of adequate intake of calcium and vitamin D
• Memory cues

Sensory/Perceptual

• Presbyopia
• Increased sensitivity to glare and decreased ability to adjust to darkness
• Arcus senilis
• Presbycusis
• Decreased sense of taste and smell
• Increased threshold for sensations of pain, touch, and temperature

Nursing interventions

• Vision/hearing screenings
• Dating and labeling foods
• Smoke alarms
• Teach safety risks for burns and other injuries

Pulmonary

• Decreased ability to expel foreign or accumulated matter
• Decreased lung expansion, less effective exhalation, reduced vital capacity, increased residual volume
• Dyspnea following intense exercise

Nursing interventions

• Cessation of smoking
• Preventing respiratory infections by washing hands
• Influenza and pneumonia vaccines

Cardiac

• Reduced cardiac output and stroke volume
• Reduced elasticity and increased rigidity of arteries
• Increase in diastolic and systolic blood pressure; orthostatic hypotension

Nursing interventions

• Periodic check-ups for blood pressure and cholesterol
• Smoking cessation
• Avoid foods high in sodium
• Eat fruits and vegetables
• Exercise

Gastrointestinal/Urinary

Gastrointestinal

• Delayed swallowing time
• Xerostomia
• Increased tendency for indigestion and constipation

Urinary

• Reduced filtering ability of the kidney and impaired renal function
• Less effective concentration of urine
• Urinary urgency and frequency; nocturnal frequency

Nursing interventions

• Oral hygiene and dental care
• Nutrition
• Colorectal screening
• Drink sufficient fluids
• Practice pelvic muscle exercises to stop or control stress incontinence

Genitalia

• Prostate enlargement in men
• Multiple changes in women (shrinkage and atrophy of the vulva, cervix, uterus, fallopian tubes, and ovaries; reduction in secretions; change in vaginal flora)
• Increased time to sexual arousal
• Decreased firmness of erection, increased refractory period (men)
• Decreased vaginal lubrication and elasticity (women)

Nursing Interventions

• Assist with hygiene as needed to maintain a clean, odor-free environment
• Encourage patients to seek professional advice from their primary care provider or other healthcare professional

Immunologic/Endocrine

Immunologic

• Decreased immune response
• Poor response to immunization
• Decreased stress response

Endocrine

• Increased insulin resistance
• Decreased thyroid function

Nursing Interventions

• Hand washing
• Diabetes screening
• Check thyroid function

Psychosocial & Developmental Changes

Psychosocial Changes and Developmental Tasks of the Older Adult

• Retirement
• Economic change
• Altered relationships with adult children/role reversal
• Grandparenting
• Relocation
• Maintaining independence and self-esteem
• Spouse or partner health
• Facing death and grieving
• Spirituality
• E-health

Erikson’s developmental task

• Integrity vs Despair

Health Assessment and Promotion

Common (but not expected) Health Issues

• Injuries
  • Falls (25% of older adults fall each year, but less than half tell their HCP)
  • Driving
• Identify and correct hazards in the home environment
• Chronic, disabling illnesses
• Drug abuse and misuse
• Polypharmacy
• Depression/Suicide
• Alcoholism
• Dementia vs delirium
• Mistreatment/elder abuse

Interventions to Promote Health in Older Adults

Safety

• Home safety measures to prevent injury
• Working smoke detectors and carbon monoxide detectors
• Motor vehicle safety reinforcement, especially for driving at night
• Older driver skills evaluation (some states require for license renewal)
• Precautions to prevent pedestrian accidents

Health Tests and Screening

Nutrition and Exercise

• Importance of well-balanced diet
• Sufficient Vitamin D and calcium to prevent osteoporosis
• Nutritional and exercise factors that may lead to CV disease (obesity, malnutrition)
• 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity
• Importance of adequate roughage and hydration

Social Interactions

• Encouraging intellectual and recreational pursuits
• Encouraging personal relationships that promote discussion of feelings, concern, and fears
• Assessment of risk factors for maltreatment
• Availability of social community centers and programs for seniors

Physiological Variable: Skin Integrity

Objectives

• Describe wound classifications and wound healing process
• Identify stressors that inhibit wound healing
• Discuss the Braden Scale
• Identify and stage pressure ulcers
• Assess & manage acute and chronic wounds

Skin—A Review

• Largest organ of the Body
  • Epidermis
  • Dermis
  • Subcutaneous tissue

Functions of skin

• Protection
• Heat regulation
• Sensory perception
• Excretion
• Synthesis of Vitamin D
• Expression/body image

Skin: Age-Related Changes

• Infant skin
  • Thinner skin/more prone to trauma (skin tears)
• Elderly skin
  • Reduced sebaceous activity = dry skin
  • Decrease sensory receptors = increased risk for injury
  • Decrease SubQ tissue = increased risk for pressure injury
  • Reduced blood flow = delayed wound healing
  • Increased capillary fragility = bruising

Maintaining Skin Integrity

• Assess
• Cleanse
• Moisturize
• Protect
• MASD

Moisture-associated skin damage (MASD)

MARSI

Wounds

• Wounds = non-intact skin

Wounds: Nursing Assessment

• Nursing Assessment:
  • Etiology
  • Severity of injury
  • Partial-thickness (epidermis)
  • Full-thickness (dermal, subQ)
  • Infection
  • Anatomic location

Wounds: Nursing Assessment

Exudate

• Color
• Amount
• Consistency

Wounds: Nursing Assessment

Surrounding Skin

• Color
• Temperature
• Swelling
• Skin condition
  • (dry, induration, etc)

Wound Healing

• Two ways for wounds to heal:
  • Regeneration (Epidermis)
  • Scar tissue formation (Deep dermal, subQ, muscle, bone)

Wound Healing

Acute Wounds

• Wounds that move rapidly and predictably through healing process
• Trauma, surgery

Chronic Wounds

• Wounds that fail to heal through normal repair process

Wound Healing Classification

Primary Intention

• Closed surgically
• Minimal risk for infection

Secondary Intention

• Left open to heal (dehisced surgical incision)
• Granulation, contraction, epithelialization

Tertiary Intention

• Delay between injury and surgical closure
• “Delayed primary closure”

Wound Healing Basics

• Regardless of wound type, all wounds follow the same process for healing:
  1. Hemostasis
  2. Inflammation
     • Control bleeding (hemostasis), establish clean wound bed (WBC’s)
  3. Proliferation/granulation
     • Rebuilding (Granulation, contraction, epithelialization)
     • Scar tissue
  4. Maturation
     • Scar tissue builds to normal strength
     • Scar tissue is never as strong as original tissue

Wound Healing Basics

• Support this healing process by:
  1. Keeping wounds clean
  2. Keeping wound beds moist (but not wet)

Factors Influencing Wound Healing

• Infection
• Diabetes
• Nutrition
• Obesity
• Smoking
• Immunosuppression/corticosteroids
• Perfusion and oxygenation
• Advanced age

Braden Scale

• Immobility is NOT the only indicator of pressure injury risk
• Using the Tool to its Full Potential
• Subscale scores of 2 or less indicate high risk
• Interventions must be implemented!

Pressure Injury Prevention, Identification and Staging

Pressure Injury Staging

• An assessment tool for describing the anatomic depth of soft tissue damage related to pressure.

Stage 1

• Intact skin with non-blanchable redness of a localized area usually over a bony prominence
• Darkly pigmented skin difficult to detect

Stage 2

• Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
• May also present as an intact or open/ruptured serum-filled blister

Stage 3

• Full-thickness tissue loss
• Subcutaneous fat may be visible but bone tendon or muscle are not exposed
• Slough may be present but does not obscure the depth of tissue loss
• May include undermining and tunneling

Stage 4

• Full thickness tissue loss with exposed bone, tendon, or muscle
• Slough or eschar may be present on some parts of the wound bed
• Often include undermining and tunneling

Deep Tissue Injury

• Purple or maroon localized area of discolored intact skin or blood filled blister related to damage of underlying soft tissue from pressure and/or shear.
• The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

Unstageable

• Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) &/or eschar (tan, brown, or black) in the wound bed.

PI Prevention

• Sensory Perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction/Shear
• Tissue Perfusion (Braden QD only)
• Medical Devices (Braden QD only)

Positioning and PI Risk

PI Prevention Interventions

• Assess and inspect skin every shift and PRN
• Reposition bed-bound patients Q2 hours (30- degree lateral left or right, supine) utilizing pillows or wedges
• Reposition chair-bound patients Q1 hour
• Use pillows/gel pads between bony prominences
• Elevate heels off bed
• Multilayer Foam Dressing

Basic Wound Care

• Moist wound healing
• Moist-to-moist dressings

Dressing Changes and Products

Typical dressing model:

1. Clean with
2. Apply topical
3. (Fill with)
4. Cover with
5. Secure with

Wound Care

Partial-thickness wounds

• Maintain moist wound surface
• Absorb exudate
• Protect/minimize pain
• Consider age, previous wound care experiences, patient tolerance/compliance, nurse labor

Full-thickness wounds

• Maintain moist wound bed
• Fill “dead” space (lightly pack)
• Absorb exudate
• If wound is dry, add moisture
  • Wound gels; change dressing more often
• If wound is wet, absorb
  • Alginate dressings; change dressing more often

Nursing Process

• Assessing
  • Wound/Skin assessment
• Analyzing (Diagnosing)
  • Potential problem (risk for infection)
  • Actual problem (pain, anxiety, body image)
• Planning and Implementing
  • Desired outcomes & goals
  • Implementing interventions
• Evaluating
  • Desired outcomes achieved? (Is the wound healing?)
  • Continue, modify, or discontinue treatment?

Oxygenation & Thermoregulation

Learning Outcomes

1. Identify stressors which could alter oxygenation.
2. Describe the signs and symptoms associated with altered respiratory functioning.
3. Using the nursing process, describe nursing care for a patient with altered respiratory functioning that will facilitate optimal wellness.
4. Describe the body's regulatory mechanism for controlling temperature.
5. Identify extraneous stressors that influence body temperature.
6. Describe the signs and symptoms, causes, complications, and nursing care of a patient with a temperature alteration.

Oxygenation

Why Is Oxygenation Important?

• Oxygen is necessary for proper functioning of all living cells.
• The absence of oxygen can lead to cellular, tissue, and organism death.

External Respiration

• “Gas exchange”
  • Pulmonary ventilation
  • Respiration
  • perfusion

Internal Respiration

Pulmonary Ventilation

• Breathing: Inspiration (inhalation) and expiration (exhalation)
• Adequate ventilation depends on:
  1. Clear airways
  2. Intact CNS and respiratory center
  3. Intact thoracic cavity
  4. Adequate pulmonary compliance and recoil

Factors Affecting Respiratory Function

• Age
• Environment
• Lifestyle
• Health Status
• Medications
• Psychological factors

Conditions Affecting The Airway

• Upper airway obstruction
• Lower airway obstruction

Conditions Affecting Movement of Air

• Breathing patterns: Eupnea vs Tachypnea vs Bradypnea vs Apnea
• Hypoventilation vs hyperventilation
• Orthopnea vs dyspnea
• Kussmaul breathing
• Cheyne-Stokes respirations
• Biot’s respirations

Alterations in Respiratory Function

• Hypoxemia
  • Reduced oxygen levels in the blood
• Hypoxia
  • Results from uncompensated hypoxemia
  • Insufficient oxygen available to cells

Acute Hypoxia

• Dyspnea, anxiety, elevated HR/RR/BP, restlessness, confusion, drowsiness, pallor, cyanosis, lightheadedness, nasal flaring

Chronic Hypoxia

• Fatigue, lethargy, altered thought processes, headaches, chest pain, enlarged heart, anorexia, constipation, decreased libido and urinary output, muscle pain, clubbing of the fingers and toes

Conditions Affecting Transport

Nursing Process: Oxygenation

• Assess
• Analyze
• Plan
• Implement
• Evaluate

Assess

Nursing History

• Current problem
• Lifestyle habits
• Presence of sputum

Physical Examination

• Inspection, percussion, palpation, auscultation
• Rate and depth of respirations, specific chest movements, shape of thorax
• Position patient assumes

Diagnostic Studies

• Cultures
• Arterial blood gas (ABG)
• Oxygen Saturation
• Pulmonary Function Tests (PFT)
• Capnography
• Bronchoscopy

Analyze

• Ineffective airway clearance r/t inability to clear secretions
• Infective breathing pattern r/t inadequate ventilation
• Impaired gas exchange r/t deficit in oxygenation
• Activity intolerance r/t insufficient physiological energy
• May cause: anxiety, fatigue, fear, powerlessness, insomnia, social isolation

Plan

• Goals for client with oxygenation problems:
  • Maintain airway
  • Improve comfort and ease of breathing
  • Maintain ventilation and oxygenation
  • Improve activity tolerance
  • Prevent risks associated with oxygenation problems

Implement

• Promote:
  • Optimal function
  • Comfort
  • Proper breathing
  • And control coughing

Evaluate

• Evaluate goals and desired outcomes identified in the planning stage.

Thermoregulation

Body Temperature

• Reflects the balance between the heat produced and the heat lost from the body.
  • Core temperature – the temperature of deep tissues; remains relatively constant
  • Surface temperature – temperature of the skin, subcutaneous tissue, and fat after transferred from core; varies in response to the environment but lower than core
  • Factors affecting the body’s heat production:

1. Basal metabolic rate
2. Muscle activity
3. Thyroid hormone output
4. Sympathetic stimulation
5. Fever

Regulation of Body Temperature

• Sensors in the periphery and in the core
• An integrator in the hypothalamus
• An effector system that adjusts the production and loss of heat
• TOO COLD: Vasoconstriction, shivering, piloerection, and increased metabolism
• TOO WARM: Vasodilation, sweating, increased respirations

Factors Influencing Heat Loss

Factors Affecting Body Temperature

• Age & biological sex
• Physical activity
• State of health
• Stress
• Environment
• Diurnal variations (circadian rhythms)

Hyperthermia: Heat Exhaustion and Heat Stroke

• Causes: extreme heat exposure or excessive heat production
• Heat Exhaustion- excessive sweating; pale; dizzy; nausea or vomiting; fainting; muscle cramps; rapid, weak pulse
• Heat Stroke – warm, flushed, dry skin; no sweating; rapid, strong pulse; delirious/unconscious; throbbing headache; seizures; temp greater than 103°F

Normal Temperature?

• Normal range varies by age. Adults: 96.4°F (35.8°C) to 99.5°F (37.5°C).
• No single temperature is normal for all people. Follow your institutional policy.

Pyrexia/Fever

• Pyrexia: A body temperature above the usual range (usually >100.4°F or 38°C)
• Hyperpyrexia: Very high fever (>106°F or 41°C)
• Causes:
  1. Infection
  2. CNS damage
  3. Tissue trauma
  4. Unknown origin

Fever: Clinical Manifestations

Onset

• Increased HR, RR
• Shivering
• Cold skin, complaints of feeling cold
• Cyanotic nail beds

Course

• Warm skin
• Increased HR, RR, thirst
• Drowsy, restless, weak

Defervescence (fever abatement/flush phase)

• Skin flushed, warm
• Sweating
• Decreased shivering
• Possible dehydration

Fever: Nursing Interventions

• Monitor vital signs and lab values
• Monitor intake and output
• Monitor skin color
• Remove excess blankets
• Provide fluids and simple carbohydrates
• Administer antipyretics (and antibiotics as applicable)
• Reduce physical activity
• Provide oral hygiene
• Tepid bath and cold packs

Hypothermia

• Core body temp below 96°F (36°C)
• Causes:
  1. Excessive heat loss
  2. Inadequate heat production
  3. Impaired hypothalamic thermoregulation
• Accidental vs Induced
• Clients at risk:
  • Cold weather sports
  • Infants and children
  • Elderly
  • Neurologic deficits
  • Alcoholics
  • Homeless
  • Infections
  • Head trauma
  • Neonates
  • Malnourished
  • Perioperative patients
  • hypothyroidism

Hypothermia: Clinical Manifestations

• Decreased body temperature
• Severe shivering
• Feelings of cold and chills
• Pale, cool, waxy skin
• Frostbite
• Decreased urinary output/RR/BP
• Weak and irregular HR
• Lack of muscle coordination
• Slurred speech
• Poor judgment
• Disorientation/amnesia/hallucinations
• Drowsiness (can lead to coma)

Hypothermia: Nursing Interventions

• Remove the stressor
• Provide warmth
• Apply dry clothing
• Keep limbs close to body
• Cover the scalp
• Supply warm fluids
• Apply warming pads/blankets/radiant warmers

Pneumonia

• Pneumonia is an infection of the lungs caused by bacteria, viruses, or fungi. It can be community-acquired, healthcare-associated, or caused by aspiration.
• Symptoms of pneumonia include:
  • Cough (may be productive with greenish or yellow or bloody mucus)
  • Fever, which may be mild or high
  • Shaking chills
  • Shortness of breath/crackles/wheezes/dyspnea
  • Confusion, especially in older adults
  • Excessive sweating and clammy skin
  • Headache
  • Loss of appetite, low energy, and fatigue
  • Sharp or stabbing chest pain that gets worse when you breathe deeply or cough

Pain Management

Learning Outcomes

• Role of Nursing Management
• Identify common types of pain
• Describe the non-pharmacologic and pharmacologic management of pain
• Differentiate tolerance, physical dependence, and psychological dependence in relation to analgesics
• Utilize the nursing process to describe nursing care for a client experiencing pain

What Is Pain?

• “An elusive and complex phenomenon”
• “Pain is whatever the person says it is, and exists whenever the person says it does”
• Response to actual or potential tissue damage (body’s defense mechanism)

The Pain Process

Nociception

1. Transduction
   • nociceptors
2. Transmission
3. Perception
4. Modulation of pain
   • Neuromodulators

Gate Control Theory

Pain Descriptions

• Quality
• Severity
• Periodicity

Types of Pain: Duration

Types of Pain: Location

• Generalized or Localized?
• Cutaneous (superficial)
• Somatic
• Visceral (splanchnic)
• Referred

Types of Pain: Etiology

Responses to Pain

• Physiologic
• Behavioral
• Affective

Factors Affecting Pain

• Ethnic and cultural values
• Family, gender, age variables
• Religious beliefs
• Environment and support people
• Anxiety and other stressors
• Previous pain experiences and meaning of pain

Nursing Management

• Nursing Care Plan for Pain

Assess

• Pain history
  • Location
  • Intensity
  • Quality
  • Pattern
  • Precipitating factors
  • Alleviating factors
  • Associated symptoms
  • Effects on ADLs
  • Past pain experience
  • Meaning of pain
  • Coping resources
  • Affective response
• Direct observation (of behaviors, physical signs of tissue damage, and secondary physiological responses of the client)
  • Facial expressions
  • Vocalizations
  • Immobilization
  • Purposeless body movements
  • Confusion/restlessness
  • Agitation/aggressiveness
  • Changes in vital signs

Wong-Baker Faces Pain Rating Scale

FLACC Scale

• Facial expressions
• leg movement
• activity
• cry