ADPIE

Assessment: deliberate systematic collection of data to determine current and past health status, including patient’s ability to function and cope. Identification actual or potential health problems, needed to formulate a nursing diagnosis. Collection and verification of data

Data Collection:

Subjective data: Information given directly from the patient ( i.e. pts perception understanding and interpretation of what is happening.

Objective Data: concrete observed and collected information

Sources of data: client ( primary source) family members, medical records

Methods of collection: Health Hx, Interviewing using open ended questioning, Physical exam, vital signs, diagnostic testing

Purpose Health Hx Nursing Dx and care plan Mange patient problems Evaluate nursing care

Steps: Collection and verification of data from primary source and secondary source the analysis of all data as a basis for developing a nursing diagnosis identifying collaborative problems and developing a plan if pt centered care.

Gather health history - Biological data- Chief complaint- Present health concerns- Past history- family history- review of systems - patient profile

Cultural considerations: consider health believes, use of alternative therapies, nutritional habits, relationship with family and personal comfort zone, perception and reporting,

Physical example: Head to toe, baseline vitals

Diagnosis: a nursing diagnosis is a clinical judgment about individual , family, or community responses to actual and potential health problems or life processes. It focuses on a client’s response to a health problem, rather than a physiological event, complication, or disease.

Critical thinking:

Decision making steps

- Interpret & analyze data- cluster findings- Group signs- Group behaviors

- Look for defining characteristics: clinical criteria or assessment findings that support an actual Dx. Clinical criteria can be either objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion.

Approach: Diagnostic reasoning: assessment data Defining Characteristics: assessment findingsClinical criteria: signs and symptoms

Components of a nursing Diagnosis:

Problem : Diagnostic label : What is the problem from the nursing assessment: NANDA

Etiology : Related to factors : what is causing the problem: 4 categories Pathophysiological, treatment relates, situational (environmental or personal), Maturational ( age related), something that can be treated by the nurse, not medical dx

Symptoms: Defining characteristics: objective and subjective data

Planning: Priorities !!! ABC Safety Maslow

Two step process: Writing measurable outcomes with pt specific goals developing nursing interventions

Expected outcomes: measurable criteria to evaluate goal achievementGoal: A broad statement describing a desired change in a client’s condition or

behavior

Outcomes:S: specificM: measurableA: AttainableR: RealisticT: Timed

Two types of goals: - Short term: achieved in one week or less- Long term: achieved in weeks or months

Nursing interventions: actions used to achieve the desired outcomes/goals

NIC: nursing intervention classification: - 3 types: independent, dependent, collaborative- 2 other classifications: direct, along with pt, or indirect, on pt’s behalf

Implementation Phase: action phase, carrying out plan of care

Critical thinking approach:- Review all NIC

- Review all consequences to nursing Dx- Determine probability of the consequences- Determine how this will affect the client

Focus on the set outcomes and goals, continuous assessment of outcomes and goals

Documentation: DAR

D: Data A: Action (intervention)R: Response (pt’s response to interventions)

Ethics in Nursing

Autonomy: right to self determination, independence, and freedom of decision, right to refuse care Beneficence: Positive action don’t to benefit others, putting their interests above your ownNonmaleficence: Do no harm Justice: fairnessVeracity: truthfulnessFidelity: being true to your word

Ethical Decision Making: Seven Step process1. Is there an ethical dilemma 2. Gather all relevant data3. Clarify Values4. Verbalize the problems 5. Identify possible courses of action 6. Negotiate a plan7. Evaluate the plan

Preventative ethics: Advance directives: decisions made by competent individual about their future health care

Living Will: Identifies treatments a person wants or does not want or wants should he or she become unable to make their own decisions – enforceable by law

Durable power of attorney for health care: A person legally designated to make health care decisions for an individual who is no longer able to make decisions for themselves

Infection control:

Chain of infection: Must have at least 3 elements

Infective agent Reservoir Portal of exit Means of transmission Portal of entry Susceptible host

Inflammation: Vascular and cellular response Inflammatory exudate Tissue repair

Inflammatory response: Always present with infection Causes: Heat, Radiation, Trauma, Allergens, Infection Local response: redness, heat, pain, swelling, loss of infection Clinical Manifestations: Increased WBC, malaise, Nausea, anorexia, increased pulse,

and respiration, fever

HAIs

Factors: Rate of contact: # of times a person comes in contact with health care worker Invasive procedures Therapy Length of stay

Two types HAIs Exogenous infections: MRSA Endogenous Infection: C. Diff

MRSA: death caused by sepsis Occurs from: skin-skin, contact with personal items, contact with infected surface Risk Factors: immunocompromised, invasive procedures, carrier

C. diff clostridium difficile: spore-forming gram-positive anaerobic bacillus, usually seen with antibiotic use, c. diff releases several toxins which attack cells and can lead to death

C. Diff clinical manifestation: Watery diarrhea (10-15*/ day) ABD cramping Fever Blood and pus in stool Nausea Dehydration Loss of appetite Weight loss

Risk factors: Antibiotic exposure GI surgery Immunocompromised

Potential complications Hypovolemia Renal failure Peritonitis: bowel perforation, toxic megacolon Death

Infection Prevention:

Chain of infection

Asepsis: Hand hygiene

Standard precautions Disinfect & Sterilize

Patient education: Hand hygiene Personal care products Cough etiquette Hygiene Peri-care

Wound Care: Prevent and manage infection Cleanse wound Removable nonviable tissue Manage exudate Maintain the wound in a moist environment Protect the wound

Pressure ulcers : localized area of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissue

Influencing factors Amount of pressure: if pressure is greater on capillary than normal capillary pressure

it will collapse- pressure occluded blood vessel tissue ischemia Tissue death

Length of time pressure is exerted Ability of tissue to tolerate externally applied pressure

Contributing Factors Shearing force: pressure exerted on the skin when it adheres to the bed and the skin

layers slide in the direction of body movement Friction Excessive Moisture

Pressure Ulcer staging

Stage 1: persistent redness in lightly pigmented skin , skin intact Stage 2: Partial thickness, loss of epidermis, dermis, or both, presents as an abrasion, intact or ruptures blister, or shallow craterStage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue, down to but not through underlying fascia. Does not expose bone, tendon, muscleStage 4: Full thickness loss can extend to muscle, bone, or supporting structures. Bone tendon, or muscle may be visible or palpable. Slough, escar, or tunneling may be present Unstageable: wound covered by eschar, may require debridementMay allow eschar to act as a physiological cover

Possible complication: Recurrence Cellulitis Chronic infection Osteomylitis

Assessment:

Stage Percentage Color Measurement Exudate: amount, color, consistency, odor Surrounding skin condition

Treatment: Document : size, stage, location, exudate, infection, pain, and tissue appearance Keep ulcer bed moist Cleanse with nontoxic solutions Debride Use adhesive membrane, ointment, or wound dressing Good nutrition Self care and signs of breakdown Initiate specialty services if needed

Musculoskeletal

Osteoporosis: Chronic progressive metabolic bone disease characterized by Porous bone Low bone mass Structural deterioration of bone tissue Increased bone fragility

More common in women because ….. Lower calcium intake then men Less bone mass because of smaller frame Bone reabsorption begins earlier and accelerates after menopause Pregnancy and breastfeeding deplete woman’s skeletal reserve of calcium Longevity increases likelihood of osteoporosis, women live longer than men

Etiology and Pathophysiology Peak bone mass is achieved before age 20 Bone loss after midlife is inevitable but rate of loss is variable In osteoporosis bone reabsorption exceeds bone deposition Occurs most commonly in spine, hips, and wrist Many drugs can interfere with bone absorption Walking is best weight baring exercise

Risk Factors Female Increased aging Family Hx White or Asian Small structure Early menopause Excess alcohol intake Cigarette smoking Anorexia Oophorectomy Sedentary lifestyle Insufficient calcium intake Low testosterone levels in men

Diagnostics

Hx and physical Bone mineral density Change in height is # 1 indicator

Osteopenia is more than normal bone loss but not yet at the level of osteoporosis

Good sources of calcium Sardines Milk Yogurt Turnip Spinach Cottage cheese Ice cream

Supplement Vitamin D

Delirium vs. Dementia

Delirium: State of temporary but acute mental confusion, common in older adults who have a short term illness

Develops in three days!!!!!Acute, sudden, unexpected

Early manifestations

Inability to concentrate Irritability Insomnia Loss of appetite Restlessness Confusion

Later Manifestations Agitation Misperception Misinterpretation Hallucinations

Manifestations are sometimes confused with dementia and depression

Key distinction is patient with delirium exhibits sudden…. Cognitive impairment Disorientation Clouded sesnorium

Dementia:

Syndrome characterized by dysfunction or loss of : Memory Orientation Attention Language Judgment Reasoning

Can manifestations …. Personality changes Behavioral problems: agitation, delusions, hallucinations

Alzheimer’s disease: #1 form of dementia, chronic progressive, degenerative disease of the brain

Age is most important risk factor, family Hx, more common in women

Caused by changes in brain structure and function: Development of plaques and tangles Loss of connection between cells and cell death Leads to brain atrophy

Pathological changes begin 5-20 years before clinical manifestation , progression is variable ranges 3-20 years

Late stages Long-term memory loss Unable to communicate Can’t perform ADLs Pt may become unresponsive, incontinent, and require total care

Diagnostics Dx of exclusion Comprehensive Pt evaluation Brain imaging Definitive dx can only be made at autopsy

SLEEP

Purpose of sleep Remains unclear Physiological and psychological Maintenance of biological function

Dreams Occur in NREM and REM Important for learning, memory, and adaptive to stress

Rest contributes Mental relaxation Freedom from anxiety State of mental, physical and spiritual activity

Sensory

Cataract: cloudy or opaque lens interferes with passage of light causing glare or blurred vision, 3rd leading cause of blindness

Etiology and Pathophysiology Age Blunt trauma Congenital factors Radiation and UV light exposure ( Tanning beds)

Long-term corticosteroid use Ocular inflammation

Senile cataract Most common Altered metabolic processes cause

- accumulation of water- Altered lens fiber structure

Clinical Manifestations Decreased vision Abnormal color perception Glaring of vision

Diagnostic studies Past medical Hx Physical examination Visual acuity Ophthalmosocy Slit lamp microscopy Glare Testing

Glaucoma

A group of disorders characterized by Increased IOP against optic nerve Optic nerve atrophy Peripheral visual field loss

Balance between aqueous production and reabsorption needed for normal level of IOP

Communication

Verbal Communication

Sign language, written, or spoken word Vocabulary Denotative and connotative meaning Pacing Intonation Clarity and brevity Timing and relevance

Nonverbal communication Body language Voice quality Manner, directness, and sincerity Dress and attire Visual aids Personal space Eye contact Emotional content Setting time place Rhythm and pacing Attitude and confidence Agenda

Silence

Actions speak loader then words

Factors influencing communication Physical and emotional factors Developmental factors Sociocultural factors Gender

Therapeutic communication Active listening Sharing observations Sharing empathy Sharing feelings Using touch Using silence Providing information Clarifying Focusing Paraphrasing Asking questions Summarizing self-disclosure Confrontation

Nontherapeutic communication Asking personal questions Giving personal opinions Changing the subject Automatic responses False reassurances Sympathy Asking for explanations Approval or disapproval Defensive responses Arguing

Respiratory

Physiology of Respiration Ventilation Compliance Diffusion Oxygen-hemoglobin dissociation Atrial blood gases Mixed venous blood gases Oximetry (finger, nose, toes) Oxygen delivery

Control of respirations Chemoreceptors

- central: respond to co2 increase- Peripheral: respond to decrease O2 levels

Pneumonia: Acute inflammation of the lungs caused by microbial organism, leading cause of death in the US from infectious disease

Etiology: Likely results when defense mechanisms become incompetent or overwhelmed Mucociliary mechanism impairment Alteration of leukocytes from malnutrition Immunosuppression from other disease processes Three ways organisms can reach the lungs: Aspiration, inhalation, and hematogenous

spread

Types of pneumonia: Community-Acquired Pneumonia: is defined as a lower respiratory tract infection of the

lung parenchyma with onset in the community or during the first 2 days of hospitalization

Hospital-Acquired pneumonia: occurs after the first 48 hours of admission and not incubated at the time of hospitalization

Aspiration pneumonia: Sequela occurring form abnormal entry of secretions or substances into the lower airway, usually follows aspiration of material from the mouth or stomach into the trachea and then into the lungs. Usually occurs 48-72 hours after aspiration

Opportunistic pneumonia: Immunocompromised patients , pts with protein-calorie malnutrition, patents who are being treated with immunosuppressive drugs, radiation, chemotherapy, and corticosteroids

Cardiovascular system

Hypertension: Persistent elevation of systolic BP equal to or greater than 140 or diastolic BP equal to or greater to 90, current use of antihypertensive medication

BP = Cardiac output * systemic vascular resistance

Sutohypertention caused by calcification of veins

Primary hypertension: No identifiable causesRisk factors

Age Alcohol Cigarette smoking DM Elevated serum lipids Excess dietary sodium Gender Family Hx Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress

Treatment and Prevention Lifestyle modifications

- Diet- exercise

Drug therapy Patient education Stress management

Secondary hypertension: Elevated BP with an identifiable cause

Congestive heart failure CHF

Right-sided Heart Failure

The right ventricle loses it’s ability to contract, causing blood to back up into the body, causing congestion. Blood backs up into the liver, the gastrointestinal tract, and extremities. the right ventricle becomes to damaged and is unable to pump blood efficiently to the lungs and left ventricle.

Causes of right-sided heart failure

left-sided heart failure lung diseases (chronic bronchitis, emphysema). congenital heart disease clots in pulmonary arteries pulmonary hypertension heart valve disease.

Left Sided Heart failure

The left side of the heart receives oxygenated blood from the lungs and pumps it into systemic circulation. As the ability to pump blood out of the left ventricle is decreased, the body does not receive enough oxygen, causing fatigue. the pressure in the veins of the lung increases causing fluid accumulation in the lungs. Resulting in shortness of breath and pulmonary edema.

Causes of left-sided heart failure

Alcohol abuse MI Cardiac infection Hypertension Hypothyroidism Leaking/narrowing valves

Clinical Manifestations Abnormal heart sounds (murmur) Abnormal lung sounds Edema Distended neck veins Hypotrophy of liver Dysrhythmias Weight gain

Fluid and electrolytes

Hypovolemia: fluid volume excess: loss of water and electrolytes, as in vomiting, diarrhea, fistulas, fever, excessive sweating, burns, blood loss, GI suctioning, and third-space fluid shift, decreases intake (anorexia, nausea, inability to access fluids. Diabetes insipidus and uncontrolled diabetes mellitus also contribute to a depletion of extracellular fluid volume.

Signs and symptoms Acute weight loss Decreased skin turgor Oliguria Concentrated urine Weak rapid pulse Capillary refill time increased Low CVP Decreased BP Dizziness Flattened neck veins Weakness Confusion Thirst Increased pulses Muscle cramps Sunken eyes

Hypervolemia: fluid volume excess: compromised regulatory mechanism, such as renal failure, heart failure, cirrhosis, over consumption of sodium containing fluids, fluid shift (treatment of burns), prolonged corticosteroid treatment, sever stress, and hyperaldosteronism contribute to fluid volume excess.

Signs and Symptoms Acute weight gain Peripheral edema Ascites Distended jugular veins Crackles in the lungs Elevated CVP SOB BP Bounding pulse and cough respiratory rate

Sodium imbalance (neurological)

Excess: Hypernatremia Thirst CNS deterioration Increased interstitial fluid Elevated body temp Swollen dry tongue and sticky mucus membrane Hallucinations Lethargy Restlessness Irritability Seizures Pulmonary edema

BP pulse

Deficit: Hyponatremia CNS deterioration

Potassium imbalance: ( cardiac)

Excess: hyperkalemia V-fib ECG changes CNS changes

Deficit: hypokalemia Bradycardia ECG changes CNS changes

DiabetesGlucose: energy

Two sources: Food: absorbed into bloodstream, insulin assists glucose into tissues and cells Liver: Stores glucose as glycogen and releases it when blood glucose levels are

low (gluconeogensis)

Type 1 Diabetes

Risk factors: Unknown Family Hx

Type 2 Diabetes

Risk Factors: Weight: high amounts of fatty tissue causes insulin resistance Inactivity: Increased weight, exercise uses up glucose, making tissue and cells

insulin sensitive Family Hx Race: African American, Hispanic, Native American, Asians Age: >45yo Gestational Diabetes Polycystic ovarian syndrome HTN High LDL/HDL

Diabetes PCs

Acute complications- diabetic ketoacidosis- Hyperosmolar hyperglycemic syndrome- Hyperglycemia- Hypoglycemia <70 can be fatal because brain needs glucose to function

Chronic complications- CVD: Atherosclerosis, PVD, cerebrovascular, HTN, dyslipidemia- Retinopathy: can lead to blindness, also at risk for cataracts and glaucoma

- Neuropathy- LE complications related to decreased sensation- Integumentary complications- Infection

Urinary

24 hour urine specimen collection: Always through away the first urine because you need to start with an empty bladder, at the end of 24 hours instruct patient to urinate, unsure that serum creatinine is determined during 24 hour period. keep collected specimen on ice or refrigerated, 24 hr urine is collected to check clearance of creatinine by the kidneys, given an estimate of the GFR, Creatinine is a waste product of protein breakdown, primarily body muscle mass, 12-24 hour urine test may also be done to test for protein in urine, it is more accurate then dipstick, persistent proteinuria usually indicates Glomeruli renal disease.

Urinary retention: the inability to empty the bladder completely despite micturition or the accumulation of urine in the bladder because of inability to urinate. Can be associated with urinary leakage or post void dribbling, called overflow urinary incontinence.

Acute urinary retention: the complete inability to pass urine via micturition, medical emergency Chronic urinary retention: incomplete bladder emptying despite urination.

2000-3000mL of urinary retention is considered a medical emergency.

Normal postvoid residual volume 50-75ml a finding of over 100ml indicates the need to repeat measurement

An abnormal PVR in an elderly pt is a measurement of > 200ml on two separate occasions

Urinary retention is caused by two different dysfunctions of the urinary system: bladder outlet obstruction and deficient detrusor contraction strength. Obstruction leads to urinary retention when the blockage is sufficiently severe so that the bladder can no longer evacuate its contents despite detrusor contraction. Common cause enlarged prostate. Deficient detrusor contraction strength leads to urinary retention when the muscle strength is no longer able to contract with enough force or for a sufficient period of time to completely empty the bladder. Common causes of deficient detrusor contraction strength are neurological diseases affecting sacral segment 2,3, and 4; long standing DM, over distention, chronic alcoholism and drugs.

URINARY TRACT INFECTION: Page 1155 Lewis

Most common bacterial infection in women, Pregnant women are at increased risk. E. coli most common cause, primarily in women. There are also fungal and parasitic infections but they are less common

Kidney infections may present as lower back pain.

When an older adult has an UTI it may manifest as confusion!!!!!!

Classification:

Upper urinary tract infection: involves renal parenchyma, pelvis, ureters, typically causes fever, chills, and flank pain

Lower urinary tract infection: confined to lower urinary tract and usually has no systematic manifestation

Pyelonephritis: inflammation of the renal parenchyma and collecting system

Cystitis: inflammation of the bladder wall

Urethritis: inflammation of urethra

Urosepsis: UTI that has spread into systemic circulation, a life threatening condition.

Uncomplicated: are infections that occur in otherwise normal urinary tract usually only involves the bladder

Complicated: are the infections that coexist with obstruction, stones, catheters, diabetes, neurological disease, pregnancy-induced changes, or an infection that is recurrent. Patients with complicated UTI’s are at risk for Pyelonephritis, renal damage, and urosepsis

UTI’s can also be classified by their natural history, for example initial infection, secondary infection, or recurrent

Bodies natural defenses against UTIs

Normal voiding with complete bladder emptying

Ureterovesical junction competence

Peristaltic activity that propels urine towards bladder.

Antibacterial properties of urine (pH<6.0) high urea concentration, and abundant glycoproteins that interfere with bacterial growth

Menopause and UTIs

Before menopause , glycogen rich epithelial cells and normal flora keep the vaginal pH acidic (3.5-4.5). In postmenopausal women, lower estrogen levels cause vaginal atrophy, a decrease and lactobacillus, and a increase in vaginal pH, increasing the risks for a UTI. Treatment giving women low dose estrogen replacement to acidify the vagina

After seven days on antibiotic therapy pcp my order a repeat UA to check for nitrates to make sure UTI has been completely eliminated

Urinary Incontinence : an under diagnosed and underreported problem that can significantly impact the quality of life and decrease independence, and my lead to compromise of the upper urinary tract. Causes may include cognitive decline, medication and underlying physical conditions, including UTI and urinary retention

Types:

Stress Incontinence: Most common type, when combined with urge incontinence is referred to as mixed incontinence, may be caused by poor pelvic muscle strength leading to possible leakage when laughing, sneezing, coughing. Education on kegal exercises. Urge Incontinence: over active bladder is common cause Reflux Incontinence: leakage with out warning may be caused by neuro defect Overflow Incontinence: caused by full bladder, possible in ability to urinate, distention Functional Incontinence: is caused by loss of cognitive function, environment, Latrogenic: is an unknown cause

Mixed Incontinence: combination of Stress and Urge incontinence

Problems with fecal incontinence may signal neurological causes for bladder problems because of shared nerve pathway. Constipation and impaction can partially obstruct the urethra, causing inadequate bladder emptying, overflow incontinence and infection.

Abnormal UA findings: Ketones, Protein, glucose, nitrates, blood

Fecal incontinence:

Occurs with Motor and sensory dysfunction Weakness or disruption of anal sphincters Nerve Damage Trauma

Constipation:

Causes: Insufficient dietary fiber Inadequate fluid intake Decreased physical activity Ignoring the urge to defecate Medications Neuro dysfunction Emotions Bowel obstruction

Watch for laxative abuse!!!!!

Stress and coping

Stress: is an experience that a person is exposed to through a stimulus or stressor. The appraisal or perception of a stressor. Stress can also be a link between environmental demands and a persons perception of those demands as challenging, threatening, or demanding. People experience stress as a consequence of daily life and stress can be helpful in stimulating thinking processes and helping people stay alert in their environment. Stress can facilitate growth and personal development. How people react to stress depends on how they view and evaluate the impact of the stressor, its effect on their situation and support at the time of the stressor, and their usual coping methods.

When stress overwhelms a person’s existing coping mechanisms, disequilibrium occurs, and a crisis results. If symptoms of stress persist beyond the duration of the stressor, the person has experiences a trauma

Stressors: disruptive forces operating with in or on any system , an event or thing that has caused an individual stress.

Appraisal: How people interpret the impact of the stressor on them selves, of what is happening and what they are able to do about it

Suicide: is caused by an inability to cope

Body’s response to stress:

Interrelationship of

Nervous system: Cerebral cortex: evaluates and plans course of action, theses functions

are involved in the perception of a stressor Limbic system: mediator of emotions and behavior. When stimulated

emotions, behaviors, and feelings can occur to ensure survival and self-preservation.

Reticular formation: contains RAS, which sends impulses contributing to the alertness to the limbic system and cerebral cortex. When stimulated the RAS increases its output of impulses leading to wakefulness, overstimulation due to stress can lead to sleep disturbances.

Hypothalamus / Pituitary: fight or flight, stimulated by limbic system, secretes neuropeptides that regulate the release of hormones by thee anterior pituitary , is central to the connection between the nervous system and endocrine system in response to stress.

Endocrine System: SNS stimulates the adrenal cortex to release epinephrine and

norepinephrine (catecholamines) , which prepare the body for fight or flight, Endorphins have an analgesic-like effects and blunt pain perception during stress situations involving painful stimuli, Corticosteroids are essential for the stress response, they produce a number of physiological responses including increased blood glucose, potentiating the actions of catecholamines on blood vessels, and inhibiting inflammation response. Corticosteroids play an important role in turning off the stress response , which if left uncontrolled can become self-destructive.

Immune system: Brain is connected to the immune system by neuroanatomic and

neuroendocrine pathways, stressors have the potential to lead to alterations in immune system function. Both acute and chronic stress can affect immune function, including decreased number and function of natural killer cells. Chronic stress induces immunosuppression

The increase in cardiac output, increase in blood glucose, increased 02 consumption, and increased metabolic rate make the stress response possible. Dilation of skeletal muscle blood vessels increase blood supply to the large muscles and provide

for quick movement, increased cerebral blood flow increases mental alertness, The increased blood volume (from increased extracellular fluid and the shunting of blood away from the GI system) helps maintain adequate circulation to vital organs I case of traumatic blood loss.

Flight or Fight response: arousal of the sympathetic nervous system. Reaction prepares you for action by increasing heart rate, diverting blood from the intestines to the brain and strained muscles, increasing blood pressure, respiratory rate, and increasing blood glucose levels

Neurphysiological responses to stress function through a negative feedback

Structures that control response to stressors:

Medulla oblongata: Controls heart rate, blood pressure, and respirations. Heart rate increases in response to impulses from sympathetic fibers and decreases with impulses from parasympathetic fibers

Reticular formation: Small cluster of neurons in the brain stem and spinal cord, continuously monitors the physiological status of the body through connections with sensory and motor tracts

Pituitary Gland: Produces hormones necessary for adaption to stress, such as ACTH, which produces cortisol. Regulates the secretion of thyroid, parathyroid, and gonadal hormones.

General adaptation Syndrome: When the body encounters a physical demand the pituitary initiates GAS

Phases of GAS

Alarm - Be Flight or Fight Ready The hypothalamus, adrenal and pituitary glands release additional hormones into the bloodstream in order for the body to be prepared for action. Breathing may become rapid and shallow, the liver releases additional glucose into the blood for energy and your heart rate may rise. The body can activate the alarm stage many times throughout the day in response to stressful situations.

Resistance - Reacting to Ongoing Stress During resistance, the body is reacting to continued stress and the requirement to constantly prepare for action by being alarmed. In this stage of the General Adaptation Syndrome, the body is using stores of energy, hormones, minerals and glucose. Symptoms such as stomach problems, muscle pains, fatigues, headaches, insomnia, intestinal problems and eating issues may present. Acute stress leads to physiologic changes that are important for adaptation

Exhaustion- Weakening of the Immune System This is the body’s response to continued long term stress. During the exhaustion stage, the body’s immune system may become weakened or there may be damage or disease to other internal organs. During exhaustion there is potential for an individual to experience physical illness as the immune system breaks down. When stress is excessive or prolonged, physiologic responses can be maladaptive and lead to harm and disease

Pain

Transduction: Noxious stimuli causes cell damage with the release of sensitizing chemicals, these substances activate noiciceptors and lead to generation of action potential

Transmission: Action potential continues from site of injury to spinal cord brainstem and thalamus thalamus to cortex for processing

Perception: Conscious experience of pain

Modulation: neurons originating in the brainstem descend to the spinal cord and release substances that inhibit nociceptive impulses

Acute/transient pain Sudden onset Less then 3 months or time for normal healing to occur

Mild to sever Generally can ID a precipitating event or illness Course of pain decreases over time and goes away as recovery occurs Can progress to chromic pain Clinical manifestations: HR,RR,BP, diaphoresis, anxiety, agitation, confusion,

urinary retention

Chronic Pain Gradual onset > 3 months Does not go away Treatment goals include: control to the extent possible, enhancing function and

quality of life

Factors Influencing Pain Physiologic Affective Cognitive Behavioral Sociocultural Spiritual Psychological Cultural

Treatment of pain Principals

1. Follow the principals of pain assessment2. Every client deserves adequate pain management3. Base the treatment on pt goals 4. Use multidisciplinary approach5. Evaluate the effectiveness of all therapies6. Use both drug/non drug therapy7. Prevent/manage med side effects8. Incorporate teaching throughout assessment and treatment

Distraction: redirection of attention onto something away from the pain

Radiating pain: sensation of pain extending from initial site of injury to another part of the body, pain feels as though it travels down or along body part

Legal

Torts: Three types

Intentional tort: Willful act that violates a person or property Assault Battery False imprisonment Intentional infliction of emotional distress Conversion of property- destruction of persons property

Quasi-intentional tort: Deformation of character: intentionally harmful

slander (spoken) Libel (written)

Invasion of privacy

Breach of confidentiality: privileged communication DR. Lawyer, priest

Unintentional Tort: Negligence: failure to act as a reasonable person wouldMalpractice: Professional negligence

Informed Consent: an active, shared decision-making process between a provider and recipient of care, three conditions must be met

1.Adequate Disclosure Adequate disclosure of the Dx Nature and purpose of the proposed treatment Risks and consequences Probability of success Availability of alternative treatment

2.Understanding and Comprehension: of the information being provided before receiving sedating preoperative medication

3. Voluntary consent: patient must not be persuaded or coerced in any way

Death and Dying

Loss: occurs throughout life after attachment forms Types of Loss:

Grief: is the emotional response to loss Bereavement: Individual’s emotional response to the loss of a loved one

Physical Manifestations: Occurs when all vital organs cease to function: irreversible cessation of circulatory and respiratory function or all functions of the brain

Brain Death: cerebral cortex stops functioning or is irreversibly damaged Coma or unresponsiveness Absence of brainstem reflexes Apnea Assessment by physician

DNR/DNI require physician’s orders and must be renewed, Transport DNI/DNR is separate

Hospice: six months from death, two admission criteria ( pt wants service, 6mths or less to live)