INTRODUCTION TO MEDICAL-SURGICAL NURSING Homeostasis -- Body is in a state of equilibrium
Disease is an impairment of the
normal physical &/or mental function -- cold = goosebumps -- fever = diaphoresis -- shock = increased pulse rate -- maintenance of a stable internal environment
Body used many adaptive measures to
maintain itself -- Many of the signs & symptoms of disease is the result of this adaptive process
It is our ability to adjust to environmental, physiological, & psychological changes that determines our ability to maintain health STRESS -- Involves two components :
-- Even the behavior we see are often Defense Mechanism for the reduction of emotional stress -- is the response of the body to demands placed on it
COMMON STRESSORS Physiological or Biological
Type of Stressor Examples Manifestations of Stress Cardiovascular / respiratory effects --Increased pulse --Increased BP --Rapid, shallow resp. Neurologic effects --Dilated pupils --Dizziness --Headaches G.I. effects --Nausea --Altered appetite --Diarrhea/constipation Endocrine effects --Increased levels glucose & cortisol
Type of Stressor Examples Manifestations of Stress --Irritability --Increased sensitivity (feelings are easily hurt) --Sadness, depression --Feeling "on edge"
of events significance --Impaired memory --Confusion --Impaired judgement --Poor decision making --Delayed response time --Altered perceptions --Inability to concentrate
Sociocultural &/or Spiritual --- Some Behavioral Manifestations of Stress include :
Exaggerated startle reflex
Type of Stressor Examples Manifestations of Stress
Job loss or
conflict --Alienation --Social isolation --Feelings of emptiness
Stress Response Adaptation
General response :
How successful a person is in adapting or coping with stress can be influenced by: -- ongoing process by which an individual adjust to stress in order to achieve homeostasis Shock Single organ/system
3 Stages of Stress When stressors are threatening or perceived to be threatening, the body activates physiological changes that ready it for FIGHT OR FLIGHT . The fight-or-flight response occurs. Long-term coping with stressors depletes adaptive energy, resulting in exhaustion. When the body has used up its adaptive energy & can no longer cope with stressors, it breaks down in disease, collapse, or death Stage One: ALARM Stage Two: RESISTANCE Stage Three: EXHAUSTION
Supportive Care 1. Health Education 2. Proper Explanations 3. Comfort Measures -- teaching stress management
Methods for treatment of stress
involves the entire health team
The nurse is the key person
regardless of what therapy used.
If stressors cause disease, then the
nursing role is to provide: -- eliminating conditions that promote stress -- promoting health behaviors to avoid stress
Stress can be reduced through " supportive
Nurses work towards supporting the normal adaptive processes used by patients to establish a state of equilibrium
recognizing emotional needs
controlling the external environment
As Florence Nightingale once said, " Put the patient in the best condition for nature to act upon him" Notes on Nursing Nurses recognize that applying stressors are also an important part of the adaptive process: How?
food, fluids, medications, exercise,
REST & SLEEP -- Characteristics
-- body is less rigid & tense -- individual seemingly unconscious -- body & mind in decreased state of activity
Adequate high quality sleep is essential for health & for physiological & psychological healing to occur It is believed that during " REM " sleep, adjustment are made that are necessary for learning & memory Need 20 hours of sleep Need 5 - 6 hours
Biologic Cycles -- can be over a long time or in a 24 hour cycle -- Examples :
changes in work schedule
exposure to constant artificial light & noise
-- Biorhythms are physical / mental cycles that reoccur in predictable patterns ( Circadian cycle ) -- When our biorhythms are disturbed, we don't feel well.
rapidly changing from one time zone
How would knowing about biological rhythms be helpful? Factors that Influence Sleep
Sleep loss can result in physical / emotional change
Decreased energy & enthusiasm
May become irritable, depressed, indifferent
Increased sensitivity to pain
Prolonged sleep deprivation can cause
hallucinations & delusions -- Symptoms frequently seen in patient who require frequent vital signs & treatments
COMMON SLEEP PROBLEMS
difficulty falling asleep
awakening in the night
-- Most incidences of insomnia resolve themselves -- if last longer than 3 weeks , may become chronic
Lie down only when sleepy
--but not just before bed
After 20 minutes, if not asleep
--get up, keep busy & occupied until ready to try again
Avoid using bed to read or
Daily exercise to increase tiredness
1. More common in children 2. Safety is a factor 3. Some drugs can cause this problem -- some antidepressants, tranquilizers, or antihistamines
1. Due to narrowing of the air passageways
2. Can be caused by position or sinus problems
Sleep Apnea (Hypopnea)
1. May experience 30 or more episodes 5. Symptoms : --hypertension --daytime fatigue --morning headache --personality changes --intellectual impairment 2. More common in men; in the obese; & increases with age 3. Can be due to obstruction of airways ; inhibited ventilatory drive, or both 4. Increased CO 2 & decreased O 2 causes person to start breathing
1. Neurological disorder 2. 125,000 in U.S have disorder -- Can occur in families 3. Safety is an issue --Only disturbs the person sharing the room 4. Treat with drugs that cause wakefulness such as Dexedrine or Ritalin
What do we mean by comfort? Dictionary Definitions: Comfort (Webster)
1. To soothe in distress or sorrow.
2. Relief from distress (absence of previous discomfort) (negative sense)
3. A person or thing that comforts
4. A state of ease and quiet enjoyment, free from worry (neutral sense)
5. Anything that makes life easy
6. Suggests the lessening of misery or grief by cheering, calming, or inspiring with hope (positive sense)
verb, noun, adjective, adverb
Relief I need help because I’m lonely.
Ease I feel totally peaceful.
Transcendence I did it! (with the help of my coach…)
What do we, as nurses, do to promote physical comfort? positioning Pain & sleep meds Quiet room Comfortable lighting Limit visitors
But physical comfort and positioning isn’t the only important type of comfort There are three more comfort themes that need to be addressed: 1. Comfort theme of self-esteem (psychospiritual)
2. Comfort theme of approach and attitudes of staff (sociocultural)
3. Comfort theme of hospital life (environment).
Technical definition of Comfort
The state of being strengthened when needs for relief , ease , and transcendence are met in four contexts of experience: physical, psychospiritual, sociocultural , and environmental
Enhanced patient comfort is positively related to engagement in Health Seeking Behaviors (HSBs)
Comfort is strengthening
When patients (and families) engage in HSBs, institutions have better outcomes
Patient satisfaction, nurse retention, costs down
Relationship of comfort (holistic outcome) to health seeking behaviors (HSBs)
External HSBs: e.g. functional status, rehab progress
Internal HSBs: e.g. healing, t-cell counts, etc.
Peaceful death: perfect for hospice and palliative care
Can be external and/or internal
-- both can cause : 1. withdrawal 2. depression 4. confusion 3. impaired problem solving 5. irritability
Solitude versus Loneliness
Stimulus is any change in the environment
that is sufficient to cause a response
Sensory Overload versus Sensory
Pain is a personal, subjective feeling
All pain is real
Unpleasant sensation caused by a
potentially harmful stimulus --nerves that receive & transmit painful stimuli
Components of Pain
1. Pain Threshold 2. Pain Tolerance Characteristics of Pain
Elderly may have atypical response
Culture may affect response
Past experience with pain
Not always in proportion to tissue damage
Pain is very demanding
The body does not adapt to pain
--easily perceived even during sleep Assessment of Pain
(What personal experiences with pain do you think will most affect your assessment & interventions for pain?)
Person must have some degree of
Anxiety & fear can intensify the
pain --Do this first before any intervention
MEMORY JOGGER FOR PAIN P Provocative or palliative
What provokes or worsens your pain?
What relieves or causes the pain to subside?
Quality or quantity
What does the pain fell like? Is it aching, intense, knifelike, burning or cramping?
Are you having pain right now? If so, is it more or less severe than usual?
To what degree does the pain affect your normal activities?
Do you have other symptoms along with pain, such as nausea or vomiting?
R Region and radiation
Where is your pain?
Does the pain radiate to other parts of your body?
How severe is your pain? How would you rat it on a 0 to 10 scale, with 0 being no pain and 10 being the worst pain imaginable?
How would you describe the intensity of your pain at its best? At its worst? Right now?
S T Timing
When did you pain begin?
At what time of day is your pain best? What time is it worst?
Is the onset sudden or gradual?
Is the pain constant or intermittent?
ACUTE PAIN VERSUS CHRONIC PAIN ACUTE CHRONIC Time span Less than 6 months More than 6 months Location Localized, associated with a specific injury Difficult to pinpoint Characteristics Often described as sharp, diminishes as healing occurs Often described as dull, diffuse, & aching Physiologic signs
Elevated heart rate
May be diaphoretic
Normal vital signs
May have loss of
weight Behavioral signs
Crying & Moaning
Complaints of pain
Loss of libido
Exhaustion & fatigue
Only complains of
pain when asked
Why do nurses tend to underestimate the characteristics of chronic pain? Intermittent Pain
Comes & goes
May be acute or chronic
Usually associated with conditions
Pain felt in another part of the body
rather than in the area diseased or injured
Areas of Referred Pain Liver Appendix Ureter Liver Heart Stomach Gallbladder Small intestines Ovary Kidney Colon Bladder
Nursing Interventions :
Establish a trusting relationship
Teach patients about their pain
A fellow nurse tells you that she only gives half the dose of narcotics to her terminal cancer patient, because of the danger of respiratory depression. What should you do ?
Give pain medication as ordered
Focus on patient's response
rather than on the size of the dose
Other treatments for pain control: -- Uses Gate theory Box with batteries Lead wires Electrodes
Transcutaneous Electrical Nerve Stimulation
(TENS) -- Stimulates release of Endorphins
if impulses reaches large nerve fibers
they close the gate to small fibers, thus relieving pain
pain is carried by
small nerve fibers
are carried by large fibers
--may need to destroy nerves --give patient a measure of control
--possible to achieve anesthesia or modify pain
--teaches patients to recognize stress-related responses Acupuncture/acupressure
Hot/Cold; imagery/distraction/ massage
1. Quiet room, dim lights, soft music 2. Distraction 3. Soothing bath; back rub 4. Humor 5. Make sure other things aren't contributing to the discomfort: (full bladder, thirst, hunger; wrinkled bed) 6. Plan activities so patient is not disturbed frequently
REHABILITATION Terms :
Allows client to achieve
optimum level of functioning
Begins with initial contact
Should be the underlying theme
of nursing care, regardless of setting --disturbance in structure or function --degree of observable and measurable impairment --how this disability limits normal level of functioning
Example : Jack injured his left leg, which caused an impairment in his ability to flex his knee 50%. Since he was a school bus driver, this handicap made him no longer able to operate the bus safely.
Case Study Mr. Thompson, age 72, suffered a left-sided brain hemorrhage 3 weeks earlier. Because of this, he was unable to speak or use his right arm or leg. He was also incontinent of urine and exhibited some right-sided facial paralysis. After 5 days in the hospital, it was determined that Mr. Thompson’s condition had stabilized, and he was transferred to a rehabilitation facility to continue the rehabilitation process. At this time, his speech had returned, but was slurred and halting.
He had minimal movement in his right arm and leg but was still unable to walk or feed himself. The incontinence of urine persisted, and he had several reddened areas on his right hip and coccyx. Before his injury Mr. Thompson had been living with only his wife of 50 years, who also was in poor health. They had no family living in the state, and she was quite concerned about how she would care for him once he was sent home.
To comprehend all that is involved in helping Mr. Thompson’s return to full functioning (if that is possible), first you need to imagine a typical day in the Thompson household and to identify all the ADL and IADL competencies required to get through the day. Next, think about all the people and services that may be necessary to prevent further injury and to increase functioning.
The Rehabilitation Team
Clinical nurse specialist
PATIENT & FAMILY Rehab Team NUTRITIONIST NURSE PSYCHOLOGIST PHYSICAL THERAPIST OCCUPATIONAL THERAPIST SOCIAL WORKER PHYSICIAN RECREATIONAL THERAPIST SPEECH THERAPIST