Care and comfort


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Care and comfort

  1. 1. I. Nutrition A. Food guidelines 1. Nutritional needs through the life cycle a. infants - fluid needs: adequate to maintain hydration (approximately 6 wet diapers per day) b. infants - protein needs are 2.2 gm/kg/day c. breast milk or formula is adequate for the first six months of life i. whole milk is difficult for young infants to digest ii. the first food introduced is rice cereal (less likely to develop allergy to rice) d. childhood - gradual increasing of all nutrients e. adult - unchanged except for i. pregnancy - add per day: 300 calories, 15 mg iron, 30 g protein, 400 g calcium, and 200 ug folic acid ii. lactation - add 500 calories and 2 quarts extra fluid per day f. elderly: over age 65 - adequate protein to maintain immune system 2. Factors affecting dietary patterns a. health status b. ability to chew, swallow, and drink c. culture and religion d. socioeconomic status e. personal preference f. psychological factors g. alcohol and drugs 3. Energy needs a. basal metabolism: amount of energy (measured in calories) required to sustain life in a resting individual b. basal metabolic rate (BMR) i. influenced by genetic and environmental factors, e.g., gender, age, activity level, body surface area, body fat percentage, diet
  2. 2. ii. several different formulas can be used to determine BMR Review the MyPyramid Food Guidance System. Learn more about Healthy People 2020, which is a statement of national health objectives and goals to reduce preventable threats to health. B. Essential nutrients 1. Carbohydrates a. includes sugars, starches and fibers (cellulose) b. simple sugars (monosaccharides and disaccharides) are most easily metabolized c. starches are more complex in structure and metabolism d. functions of carbohydrates i. quickest source of energy (4 kcal/gram) ii. main source of fuel for brain, peripheral nerves, WBCs, RBCs, and healing wounds iii. protein sparer e. dietary sources: plant foods, except for lactose f. recommended daily intake: i. factors influencing recommended intake of carbohydrates include body structure, energy expenditure, basal metabolism and general health status ii. ideally, 50 to 60% of total calories should be complex carbohydrates g. excessive carbohydrate calories are stored as fat 2. Lipids a. basic lipids are composed of triglycerides and fatty acids b. includes saturated fatty acids (from animal sources) and unsaturated fatty acids (vegetables, nuts and seeds) c. essential polyunsaturated fatty acids: linoleic and linolenic fatty acids are the only fatty acids that are essential to humans d. deficiencies lead to skin, blood and artery problems e. functions i. most concentrated source of energy (9 kcal/gram) ii. major form of stored energy iii. insulation iv. component of cell membranes v. carries fat-soluble vitamins A, D, E and K f. recommended dietary intake: total fat intake should not exceed 30% of daily calories with saturated fats not exceeding 10% of total daily caloric intake Take care of yourself when preparing to take the NCLEX exam. Get plenty of rest, exercise regularly, eat nutritious meals, and stay hydrated with noncaffeinated beverages.3. Proteins a. complex organic compounds comprised of amino acids
  3. 3. b. body breaks protein down into 22 amino acids c. all but eight amino acids are produced by the body d. "complete protein" food - contains the eight essential amino acids not produced by the body (most meat, fish, poultry and dairy products) e. "incomplete protein" food - lacks one or more of the eight amino acids (most vegetables and fruits) f. incomplete proteins can be combined to yield a complete protein: for example, beans and rice g. functions of protein i. secondary energy source (4 kcal/gram) ii. essential for cell growth iii. efficiency can affect all of body - organs, tissues, skin, muscles iv. recommended protein intake: 0.8 grams per kg of body weight per day v. the bodys only source of nitrogen vi. negative nitrogen balance can occur with infection, burns, fever, starvation, and injury4. Vitamins a. organic substances essential for body growth and metabolism b. found only in plants and animals; body cannot synthesize them; depends on dietary intake c. types (according to their solvent) i. water soluble: vitamin C and B-complex vitamins (thiamin, riboflavin, niacin, pantothenic acid, biotin, B6, folate, B12) cannot be stored in body require daily intake ii. fat soluble: A, D, E, K stored primarily in the liver and adipose tissues absorbed by the body from the intestinal tract 5. Minerals a. inorganic substances essential as catalysts in biochemical reactions b. form most inorganic material in the body c. functions: i. catalyst for many body reactions such as regulation of acid-base balance ii. help cells metabolize, tissues absorb nutrients, and heart muscle respond iii. minerals work synergistically; a deficiency of one mineral can disturb the action of other minerals iv. types - grouped according to amount found in body major minerals - calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine (function is known) trace minerals - iron, copper, iodine, manganese, cobalt, zinc and molybdenum (function unclear) another group of trace minerals; found in even smaller amounts (function is unclear) 6. Water a. critical body component essential for cell function b. accounts for 60 to 70% of total body weight in adults; 70 to 75% of total body weight of children c. provides normal turgor d. regulates body temperature
  4. 4. e. dietary sources: liquids and solids, such as fresh fruits and vegetables f. deficiency: severe deficiency leads to dehydration and death g. fluid intake normally equals fluid output Learn more about nutrition from the Amercian Dietetic Association.Fluid and electrolyte balance 1. Total volume of fluid and amount of electrolytes remain relatively constant in the body 2. Fluid balance and electrolyte balance is interdependent 3. Body balances fluid and electrolytes primarily by adjusting output and secondarily by adjusting intake 4. Fluid balance is also maintained by osmosis 5. Major electrolytes a. cations i. sodium - most abundant cation in extracellular fluid regulates cell size via osmosis essential in maintaining water balance, transmitting nerve impulses, and contracting muscles regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney normal lab value for serum sodium is 135 to 145 mEq/L sodium is regulated by salt intake, aldosterone, and urinary output sources include table salt, processed meats, snacks and canned food ii. potassium - most abundant cation of intracellular fluid potassium pump draws potassium into cell essential for polarization and repolarization of nerve and muscle fibers regulates neuromuscular excitability and muscle contraction sources include whole grains, meat, legumes, fruits and vegetables regulated by kidneys normal lab value for serum potassium is 3.5 to 5.3 mEq/L iii. calcium - essential for healthy bones and teeth, cell membrane integrity, blood clotting, cardiac contraction, blood pressure, functioning of nerves and muscles and maintaining immune defenses iv. magnesium - normal constituent of bone; cofactor for enzymes in energy metabolism, neurochemical activities, muscular excitability b. anions i. chloride - most abundant anion in extracellular fluid; part of hydrochloric acid found in stomach and necessary for proper digestion; helps balance sodium; normal lab value for serum chloride is 100 to 106 mEq/L ii. bicarbonate - part of bicarbonate buffer system; limits the drop in pH by combining with an acid to form carbonic acid and a salt iii. phosphate - participates in cellular energy metabolism, combines with calcium in bone, assists in structure of genetic materialMaintenance of fluid volume a. osmoreceptor system i. balances fluid intake volume by the regulation of water output volume
  5. 5. ii. dehydration stimulates osmoreceptors which activate the thirst control center; person feels thirsty and seeks water iii. also stimulates antidiuretic hormone (ADH) secretion which decreases urinary output by causing the reabsorption of water in the tubulesb. circulatory system i. increases in fluid intake increase circulatory volume ii. this increased volume stimulates the kidneys for an increased glomerular filtration rate iii. end result is an increase in urine output to decrease the initial circulatory volumec. thirst center i. located in hypothalamus ii. stimulated by increased plasma osmolality angiotensin II dry pharyngeal mucous membranes decreased plasma volume depleted potassium psychological factorsd. Maintenance of electrolyte balance i. aldosterone - hormone (mineralocorticoid) when extracellular fluid sodium decreases or potassium levels increase adrenal cortex secretes aldosterone kidneys stimulated by aldosterone to increase reabsorption of sodium and decrease reabsorption of potassium results in water reabsorption and increased blood volume ii. renin/angiotensin - hormone affecting renal tubule reabsorption of water iii. atrial natriuretic peptide (ANP) - hormone affecting renal tubule reabsorption of water iv. parathyroid parathyroid secretes parathyroid hormone (PTH), also called parathormone stimulates release of calcium from bone, reabsorption in small intestine and kidney tubules when serum calcium level is low, PTH secretion increases when serum calcium level rises, PTH secretion falls high levels of active vitamin D inhibit PTH and low levels or magnesium stimulate PTH secretion
  6. 6. D. Normal and therapeutic diets 1. Guidelines: a. dietary reference intakes (DRIs) - average daily nutrient intake of apparently healthy people over time i. recommended dietary allowance (RDA) ii. adequate intake (AI) iii. tolerable upper intake level (UL) iv. estimated average requirement (EAR) b. ethnic food patterns c. religious considerations in meal planning d. personal choice, e.g. vegetarian Types of vegetarian diets: Vegan: refrains from eating animal products Lacto-ovo vegetarian : consumes eggs and dairy products but excludes meat, poultry, seafood Lacto vegetarian : consumes dairy products, but excludes eggs, meat, poultry, seafood2. Therapeutic nutrition a. modification of the nutritional needs based on disease condition b. considerations for administering therapeutic diets i. condition of client - physical, emotional, mental ability of client to tolerate diet ii. willingness of client to follow dietary guidelines c. types of therapeutic diets i. diabetic goals of nutritional management
  7. 7.  providing all essential nutrients  meeting energy needs  achieving and maintaining a reasonable weight  preventing wide daily fluctuations in blood glucose levels  decreasing serum lipid levels diet individualized according to clients age, build, weight, and activity level recommended caloric distribution: 50-60% carbohydrates, 20-30% fat, and 10-20% protein The American Diabetes Association provides comprehensive information about diabetes. ii. low protein diet for renal disease such as pyelonephritis, uremia, kidney failure limit protein less than 40 g/day (0.5 g/kg/day) instead of normal protein intake of 40 to 60 g/day (1g/kg/day) restricted foods: meats and other foods high in protein such as legumes, fish, dairy iii. high protein diet for conditions such as burns, anemia, malabsorption syndromes, ulcerative colitis include high quality proteins or protein supplements such as Sustagen® promote high protein intake more than 60 g/day (1.5 g/kg/day) instead of normal protein intake of 40 to 60 g/day (1g/kg/day) iv. low calcium diet limit to 400 mg per day instead of normal 800 mg restricts dried fruits and vegetables, shell fish, cheese, nuts v. acid ash diet prevents kidney stone formation restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives, pickles vi. low purine diet prevents uric acid stone; used for clients with gout lowers levels of purine, the precursor of uric acid restricts glandular meats, gravies, fowl, anchovies, beer and wine (see gout dietfor more details)vii. gluten-restricted or gluten-free used for people with sensitivity to glutens (proteins) in wheat, oats, rye, and barley may eat rice, corn and millet productsviii. low cholesterol used for cardiovascular disease, high serum cholesterol levels normal amount of cholesterol intake - 250 to 300 mg/day restricts eggs, beef, liver, lobster, ice cream ix. low sodium used in congestive heart failure, hypertension used for correcting the retention of sodium and water levels of restriction
  8. 8. i. mild (2 g sodium) ii. moderate (1000 mg sodium) iii. strict (500 mg sodium) restricts table salt, canned vegetables, smoked meats, butter, cheese x. high fiber used to correct constipation, lower risk of colon cancer 30 to 40 gram fiber/day recommended increased intake of fruits, vegetables, bran cereals xi. low residue used for conditions such as diarrhea, diverticulitis reduce fiber intake: canned fruit, refined carbohydrates, pasta, strained vegetables foods high in refined carbohydrates are usually low fiber increased use of ground meat, fish, broiled chicken without skin, white breadxii. mechanical soft used with difficulty in chewing, such as poorly fitted dentures or endentulous clients (no teeth) includes any foods which can be easily broken down by chewingxiii. puree diet used with dysphagia or difficulty in chewing used for tube feedings, small babies food is blended to smooth consistencyxiv. liquid diets clear liquid: coffee without cream, tea, popsicles, fruit juices, including apple, cranberry, grape, and carbonated beverages full liquid: includes all clear liquids plus milk, cream, ice cream, pudding, yogurt, vegetable juice, creamy peanut butterxv. Nutritional assessment weight change appetite food intolerance chewing and swallowing indigestion elimination habits eating behaviors nutrient-drug interactions anthropometric measurementsxvi. Feeding tubes indications - inability to ingest, chew, or swallow food, but GI tract intact tube inserted through nose into stomach or small bowel; or inserted endoscopically; gastrostomy tube or PEG tube, jejunostomy tube types of tubes and feedings
  9. 9. i. small bore feeding tube: 8 to 12 Fr and 36 to 43 inches long i. difficult to aspirate stomach contents ii. may be impossible to auscultate an air bolus or air bolus may be heard even when tube is not in stomach iii. tubes may become displaced even when securely taped iv. hard to verify placement; therefore best initial method is by x-ray; thereafter routine check of stomach contents pHxvii. enteral tube feedings keep head of bed raised at least 30 degrees, to prevent aspiration
  10. 10. assess placement of tube (confirm technique used, as required by agency policy) i. obtain radiologic (x-ray) confirmation before instilling any feedings or medications or if there are concerns about other forms of assessment ii. recommended practice is to aspirate gastric contents and check if pH is acidic (pH should be below 6) iii. injecting ten mL air into nasogastric tube (NG tube) and listening with stethoscope for rush of air over stomach is no longer an accepted method to verify placement administer enteral feeding i. may be continuous or intermittent ii. to prevent bacterial growth, change bag and tubing every 24 hours and tube feeding formula every 4 to 8 hours iii. to prevent fluid and electrolyte imbalances, administer tube feedings at a rate of no more than 300 mL/hr assess gastric residual i. every 4 hours if continuous feeding or ii. before you begin intermittent feedingsxviii. tube feeding formulas: Vivonex®, Isocal, Portagen®, etc. xix. complications aspiration gastrointestinal complications (diarrhea) electrolyte or metabolic problems xx. Nutritional supplements and liquids for dehydration or diarrhea infants: Infalyte, Pedialyte®, Ricelyte® older children: sports electrolyte replacement drinks infant formulas: standard and high-calorie specialty formulas: i. predigested, e.g., Pregestimil, Nutramigen ii. high-calorie supplements, e.g., Scandishake, Carnation Instant Breakfastxxi. Parenteral nutrition: see Lesson 6 of this coursexxii. Measures to improve nutrition intake of client frequent small feedings feeding assistance offering preferred foods ethnic foods It is more productive to review materials frequently in short intervals, such as one-to-two hours at a time. Be sure to take a short break every half hour or so.Mobility A. Prevent complications of immobility 1. Skin changes - decubitus ulcers a. turn and reposition client every 2 hours b. use heel/elbow protectors c. use alternate pressure mattress or other skin care devices d. do not massage reddened areas; doing so increases potential damage to tissues
  11. 11. e. limit sitting in a chair to 2 to 4 hours or as tolerated with a shift in weight at least every 30 to 60 minutes2. Musculoskeletal changes, especially contractures a. perform range of motion exercises to joints on a scheduled basis daily b. provide foot board and/or foot cradle or high-topped tennis shoes to prevent foot drop c. reposition every 2 hours d. maintain correct body alignment3. Respiratory changes - pneumonia, atelectasis a. instruct client to cough and deep breathe every 2 hours, or more frequently b. turn every 2 hours c. suction if needed d. chest physiotherapy (percussion & drainage) as ordered4. Cardiovascular system changes-decreased cardiac output, clots,emboli a. orthostatic hypotension i. instruct client to change position slowly, moving progressively from lying to sitting to standing position ii. highest risk is from supine to standing position b. increased cardiac workload i. instruct client to avoid bearing down (Valsalvas maneuver) ii. minimize coughing iii. limit sitting in high Fowlers position to 1 to 2 hours c. thrombus/emboli formation i. apply thigh or knee-high anti-embolic stockings as ordered and/or intermittent pneumatic compression devices ii.turn every 2 hours iii.monitor anticoagulation therapy, as indicated iv. initiate ambulation or assist client with dorsiflexion and plantar flexion of the foot v. limit sitting with feet in a dependent position to 1 to 2 hours5. Urinary changes
  12. 12. a. renal, calculi, urinary tract infection, glomerular nephritis b. increase fluid intake (2000 to 3000 mL/day) 6. Psychosocial changes a. interact with client and orient as needed b. develop and follow mutually agreeable activity schedule with client to help maintain mental sharpness B. Types of exercise 1. Passive: carried out by the health care provider without assistance from client; purpose is to retain joint mobility and blood circulation 2. Resistive: carried out by the client working against resistance; purpose is to increase muscular strength; enhance bone integrity 3. Isometric: carried out by the client with no assistance by contracting muscle group for ten seconds and then relaxing muscle group; purpose is to maintain muscular strength when the joint is immobilized 4. Range of motion (ROM): joint is moved through entire range of motion; purpose is to maintain joint mobilityUse of mechanical aids to promote mobility 1. Crutches - provides support and assists ambulation for people with weight-bearing restrictions a. keep tips of crutches 8 to 12 inches to side of feet b. adjust handbars to allow 15 to 30 degrees of elbow flexion c. use well fitting shoes with nonslip soles d. use non-skid, rubber tips on crutches i. inspect weekly ii. replace when worn e. may be used temporarily or permanently f. teach client crutch walking 2. Cane - provides stability when walking and relieves pressure on weight-bearing joints a. adjust cane with handle at level of greater trochanter, elbow flexed at 30 degree angle b. teach client to hold cane close to body, and hold in hand on stronger side c. move cane at same time as the weaker leg 3. Walker - provides support, stability, and balance for people without weight-bearing restrictions a. client must be strong enough to pick walker up and move it forward before taking the next step (walkers with wheels are available for clients who are not strong enough to lift a walker but who can slide it forward) b. teach client how to sit, stand and turn c. do not allow client to place hands on walker to stand from sitting position (it is unstable) 4. Gait belt a. usually a canvas belt, with or without handles, positioned over the clients clothing b. the gait belt should fit tightly around the waist c. safety devices for ambulatory clients who may have some balance problems 5. Prosthetic devices - used to replace a missing body part 6. Brace - support for weakened muscles 7. Elimination a. Promotion of normal elimination i. Urination 1. adequate fluid intake
  13. 13. 2. adult urinary output - minimum 30 mL/hour 3. alternative methods to promote client voiding include running water ii. Bowel elimination 1. adequate fluid intake 2. regular exercise 3. regulate fruit juices, raw fruits and vegetables as needed 4. normal bowel evacuation varies in healthy individuals; no more than 3 movements per day to 3 times a week b. Urinary incontinence: involuntary release of urine i. Types 1. stress incontinence: sudden increase in intra-abdominal pressure (such as sneezing, coughing) causes urine to leak from bladder 2. overflow (reflex) incontinence: bladder empties incompletely, so urine dribbles constantly 3. urge incontinence: uncontrolled contraction of the bladder results in leakage of urine before one reaches the bathroom 4. functional incontinence: incontinence not due to organic reasons; for instance, impaired mobility may prevent the client from reaching the bathroom in time Remember the reversible causes of urinary incontinence using the mnemonic D.R.I.P. D elirium R estricted mobility (or Retention [urinary]) I nfection (or Inflammation or Impaction [fecal]) P harmaceuticals (or Polyuric states)2. Diagnosis of urinary incontinence a. history and physical examination b. urinalysis - tells whether blood or infection present c. cystoscopy - tells whether abnormalities are present d. post-void residual - measures amount of urine remaining in bladder after voiding e. stress test - determines if urine leaks after bladder is stressed due to coughing, lifting etc.3. Treatment a. pharmacologic therapy i. antispasmodics and anticholinergics - relax and increase capacity of bladder ii. alpha-adrenergic agonists - increase urethral resistance b. Kegel exercises strengthen weak muscles around the bladder c. behavioral training - client learns different way to control urge to urinate d. bladder retraining e. surgery - repair of weakened or damaged pelvic muscles or urethra4. Nursing interventions a. provide skin care, protective undergarments b. establish toileting schedule - provide easy access to bathroom and privacy c. teach client Kegel exercises: i. stop and start urinary stream while voiding ii. hold contraction for 10 seconds and relax for 10 seconds iii. work up to 25 repetitions three times a day
  14. 14. d. prevent infection i. cleanse urethral meatus after each void ii. acidify urine iii. increase daily intake of fluids Learn more about incontinence from the National Association for ContinenceC. Catheterization 1. Purposes a. relieve acute urinary retention b. relieve chronic urinary retention c. drain urine preoperatively and postoperatively d. accurately measure output in the critically ill e. continuous or intermittent bladder irrigation 2. Types of catheters and general guidelines a. indwelling catheter i. use a closed drainage system ii. advance catheter almost to bifurcation of catheter, especially in male clients iii. inflate balloon within guidelines of manufacturer only after urine is draining properly, then slightly withdraw catheter iv. secure catheter to patients thigh, allowing for some slack to accommodate movement and to lessen drag on patient; ensure tubing is over clients leg v. monitor intake and output vi. care of indwelling catheter:
  15. 15. cleanse around area where catheter enters urethral meatus, using soap and water catheter care should be done during the daily bathing routine and after defecation do not pull on catheter while cleansing do not use powder or spray around perineal area maintain a closed drainage system avoid raising the drainage bag above the level of the bladder avoid clamping the drainage tubing catheter is only irrigated when an obstruction, usually following prostate or bladder surgery when blood clots are anticipated remove catheter when no longer medically necessary - use a decision-making algorithm for determining when to remove the catheter The Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTI) is an excellent resource for the prevention of CAUTI. Listen to a CDC podcast about catheter-associated CAUTIs. b. suprapubic catheter i. placed to drain the bladder ii. achieved via a percutaneous catheter or by way of an incision through the abdominal wall c. intermittent self-catheterization i. purpose: to drain the bladder ii. employed by the client with spina bifida and other neuromuscular diseases; can be taught to children ages 6 to 8 years-old iii. procedure: gather equipment: catheter, water-soluble lubricant, soap, water, urine collection container wash hands cleanse urethral meatus and surrounding area lubricate tip of catheter insert catheter until urine flows withdraw catheter when urine flow stops clean off residual lubricant from meatus dispose of urine wash handsOstomies 1. Types of ostomies a. ileostomy i. liquid to semi-formed stool, dependent upon amount of bowel removed ii. may skew fluid and electrolyte balance, especially potassium and sodium iii. digestive enzymes in stool irritate skin
  16. 16. iv. do not give laxatives v. ileostomy lavage may be done if needed to clear food blockage vi. may not require appliance; if continent ileal reservoir or Kock pouch b. colostomy i. ascending - must wear appliance - semi-liquid stool ii. transverse - wear appliance - semi-formed stool iii. loop stoma proximal end - functioning stoma distal end - drains mucous plastic rod used to keep loop out usually temporary iv. double barrel 2 stomas similar to loop but bowel is surgically severed v. sigmoid formed stool bowel can be regulated so appliance not needed may be irrigated 2. Stoma assessment a. color - should be same color as mucous membranes b. edema - common after surgery c. bleeding - slight bleeding common after surgery 3. Psychological reaction to ostomy a. disturbed body image b. anxiety related to feared rejection c. ineffective coping related to ostomy careSleep A. Factors affecting sleep
  17. 17. 1. Physical illness 2. Drugs 3. Lifestyle 4. Excessive daytime sleep 5. Emotional stress 6. Environment 7. Exercise/fatigue 8. Food intakeB. Sleep disorders 1. Bruxism: tooth grinding during sleep 2. Insomnia: chronic difficulty with sleep patterns a. initial insomnia: difficulty falling asleep b. intermittent insomnia: difficulty remaining asleep c. terminal insomnia: difficulty going back to sleep 3. Narcolepsy: fall asleep without warning 4. Sleep apnea: intermittent periods of not breathing while asleep a. usually due to problems with upper airway b. can be treated with a continuous positive airway pressure (CPAP) machine at bedtime 5. Sleep deprivation: decrease in the amount and quality of sleep 6. Somnambulism: sleepwalking, night terrors, or nightmares 7. Depression a. secondary to disease process b. can occur with any sleep disorderC. General nursing interventions for promoting restorative sleep 1. Comfort measures 2. Pharmacologic: sedatives, hypnotics 3. Sleep routine 4. Encourage daytime activity 5. Eliminate naps
  18. 18. 6. Relaxation techniques 7. Environmental control 8. Limit alcohol, caffeine, and nicotine in evening D. Pain 1. Theories of pain a. Specificity theory proposes that pain can be initiated only by painful stimuli b. Pattern theory - stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and muscles to respond. c. Gate control theory - pain impulses can be altered or regulated by gating mechanisms along nerve pathways;it explains how past and present experiences can influence the perception of pain 2. Variables influencing the perception of pain a. Culture and social groups shape attitude towards pain b. Religious beliefs regarding reasons for pain c. Previous experience with pain d. Age e. Gender f. Coping style g. Family support 3. Types of pain a. Acute pain A. may last up to 6 months B. due to an identifiable cause, for example, surgery, injury, trauma C. if not relieved can lead to chronic pain conditions D. clients may exhibit changes in vital signs b. Chronic pain A. lasting beyond the expected healing period B. lasting longer than 6 months C. intermittent or constant D. cause is not easily identified since physical evidence may not be evident E. changes in vital signs may not occur F. affects all areas of a patients life G. often associated with depression includes standards of care, interactive learning activities with case studies and resources for pain management. American Society of Pain Management Nursing is used by nurses for education, resources, and to access pain management courses. The American Chronic Pain Association provides resources and coping strategies for those affected by chronic pain. Be sure to refer to the Relaxation Guide.Medical treatment 1. Pharmacologic intervention (discussed in Lesson 6: Pharmacological and Parenteral Therapies)
  19. 19. 2. Complementary and alternative therapies: used not only for pain management but to improve sleep, reduce anxiety, improve mood, and increase the patients sense of control over the environment a. Acupuncture i. several methods of stimulation at specified body sites, including, insertion of fine needles or electro stimulation or laser beams or ultrasound waves ii. despite being one of the most widely researched of all CAM/complementary and alternative therapies it remains unknown how acupuncture works physiologically b. relaxation techniques - biofeedback, visualization, meditation and hypnosis c. electronic stimulation such as transcutaneous electric nerve stimulation (TENS) - electrodes applied over the painful area or along nerve pathway d. distraction - focusing clients attention on something other than pain; more useful with short term pain rather than long term pain e. massage - generalized cutaneous stimulation of the body f. cooling and heating therapies i. uses for cooling or heating vary with the origin of the pain ii. cooling or heating are both useful for well-localized pain iii. ice may decrease prostaglandins which intensify the sensitivity of pain receptors g. guided imagery i. mental images imagined by the patient or suggested by the clinician may be used for relaxation or distraction ii. some methods of imagery are designed to reduce pain h. music therapy i. uses rhythmic sound to create a feeling of well-being, encourage healing, enhance relaxation ii. includes singing, moving to music, listening, creating music, drumming solo or group drumming
  20. 20. i. osteopathic manipulation: takes the perspective that structure directly influences function and uses physical manipulation to stimulate the bodys self healing j. yoga: promotes health and wellness through integration of body, mind, and spirit i. useful in circumstances of chronic pain ii. useful for any patient age group iii. may be adapted for use by patients with physical limitations 3. Nursing interventions in pain a. assess using pain assessment scale (faces for children or cognitively impaired [Wong-Baker FACES scale] or number scale ranging from 0 to 10) b. assess clients coping strategies and factors that produce ineffective coping c. teach client appropriate strategies to deal with painCommunication A. Cross-cultural communication guidelines 1. Findings of a nontherapeutic communication a. efforts to change the subject - client may not understand what the nurse is saying b. lack of questions - client may not understand what was said c. nonverbal cues - blank expression, lack of eye contact 2. Nursing interventions and therapeutic communication a. use simple sentence structure and gestures while talking b. use visual aids c. discuss one topic at a time d. use any words you know in the clients language e. use a medical interpreter service for verbal communication - avoid using family members as interpreters f. obtain phrase books or use flash cards 3. Cultural interpretations a. silence b. touch c. eye contact B. Client with hearing loss 1. Findings of hearing loss a. speech deterioration b. indifference c. social withdrawal d. suspicion e. tendency to dominate conversation 2. Nursing interventions a. speak slowly and distinctly; do not shout b. face client directly c. make sure your face is clearly visible d. before the discussion, tell client the topic you are going to discuss e. insure that client has access to hearing aid and that it is functional f. keep sentences short and simple g. use written information to enhance spoken word C. Client with aphasia 1. Injured cerebral cortex blocks some language-related functions 2. Types of aphasia a. global aphasia: individuals can neither read nor write
  21. 21. b. Brocas aphasia ("non-fluent" aphasia): speech is affected; the client may understand speech and be able to read but has limited writing ability c. Wernickes aphasia ("fluent" aphasia): inability to understand the meaning of spoken words and reading and writing is impaired; able to speak but speech is not normal 3. Nursing interventions a. face client and establish eye contact b. avoid completing clients statements c. use gestures, pictures, and communication boards d. limit conversation to practical matters e. use the same words and gestures for objects f. keep background noise to a minimum and turn off competing sounds, e.g., radio, television g. do not shout or speak loudly h. give the client time to understand and respond i. if client has problems speaking, ask "yes" or "no" questions When you are taking the NCLEX-RN® exam, NEVER guess! Instead, maintain a reasonable pace (no more than one to two minutes on each item) and carefully read and consider each item before answering. D. Client with stroke 1. Approach client from side of intact field of vision 2. Remind client to turn head in direction of visual loss to compensate for loss of visual field 3. Explain location of object when placing it near the client 4. Always put client care items in same places 5. Put objects within clients reach, and on unaffected side 6. Encourage client to repeat sounds of the alphabet 7. Speak slowly and clearly 8. Use simple sentences with gestures or pictures 9. Reorient client to time, place, and situation 10. Provide familiar objects 11. Minimize distractions 12. Repeat and reinforce instructions E. Client with dementia 1. Be calm and unhurried 2. Keep conversations short and focused 3. Do not ask the client to make decisions 4. Be consistent 5. Avoid distractions 6. Use reality orientation techniques Communication with individuals with aphasia or dementia is enhanced if you remember the K.I.S.S. technique: K eep I t S hort and S imple!Alternative and Complementary Medicine
  22. 22. A. Herbal therapy 1. Used as dried herbs in capsules or tablets, tinctures, teas, ointments 2. Over 600 herbal products, many of which interact with prescribed drugs, particularly cardiac drugs and antidepressants 3. St. Johns Wort is the number one herbal product a. interacts with over 60 percent of all prescription drugs b. the interaction is to make drugs less effective, including digoxin, cyclosporine tamoxifen, highly active antiretroviral therapies (HAART) and combined oral contraceptives 4. Client assessment a. ask client directly about use of herbal preparations including name of herb and manufacturer, dosages, schedule, effectiveness, rationale for use b. assess clients understanding of use of herbal preparations in conjunction with traditional Western medications and assess for interactions, adverse effects, effectivenessB. Aromatherapy 1. Over 70 therapeutic grade essential oils currently available with more being discovered and researched 2. Examples of essential oils: lavender, rose, peppermint, sandalwood 3. Methods of delivery a. inhalation - for example, use of diffuser or humidifier b. topical - for example, direct application of oil onto skin or in bath water c. internal use - for example, in capsule form, use in cooking, taken with food 4. Used for physical, mental, emotional, and spiritual conditions, i.e., relaxation and sleep; improved concentration and mental focus; soothing minor irritations and inflammation; easing stress and despair; improving ability to visualize 5. May be used in conjunction with other modalities to increase their effectivenessC. Therapeutic massage 1. Manipulates the soft tissue of the body and assists with healing 2. Physiologic effects: primarily improves circulation, oxygenation, perfusion 3. Research findings indicate: muscle relaxation, reduction of some types of pain, sedative effect on nervous system, increased peristalsis, increased lymphatic circulation 4. Can be relaxing or energizing 5. Is contraindicated for a client with phlebitis, thrombosis, varicose veins, diabetes, pitting edemaD. Reflexology 1. Pressure applied to specific areas of the feet thought to correspond with all the different parts of the body 2. Uses - relieves stress and muscle tension; promotes relaxation and sleep 3. Research - significant reduction of symptoms of premenstrual syndromeE. Relaxation therapy 1. Examples a. Rhythmic breathing b. Progressive relaxation c. Hypnosis with suggested deep relaxation 2. Relaxation response results in the following: a. decreased oxygen consumption b. decreased metabolism c. decreased cardiac and respiratory rates d. increased alpha brain waves associated with a feeling of well-being e. decreased blood lactate (associated with skeletal muscle metabolism and anxiety)
  23. 23. Explore: The Journal of Science and Healing is a bi-monthly interdisciplinary periodical with free online access to full text articles. Articles explore the relationship between health and the healing arts, consciousness, spirituality, eco-environmental issues, and basic science. F. Hypnosis: used in the treatment of many disorders, including osteoarthritis, rheumatoid arthritis, sciatica, whiplash, chronic pain; also used to replace traditional surgical anesthesia G. Yoga 1. Treatment of the mind-body connection 2. Can tone the muscles that balance all parts of the body and control the emotions and mind through correct posture and breathing H. Acupuncture - a traditional Chinese therapy using tiny needles placed in the skin to help regulate the flow of (qi) vital energy through the bodyNutrition & Fluid Intake All individuals require the same nutrients, but the amounts vary according to factors such as age, weight, activity level, and health state. The energy value of foods is defined in calories; only proteins, fats and carbohydrates provide calories. Essential amino acids cannot be synthesized; they must be ingested daily. Weight is maintained when daily food intake equals energy expenditure. Weight loss is a long-term process and patients need long-term support. Increased fiber in the diet may cause flatulence. The normal thirst mechanism in the elderly may be diminished and they may need encouragement to drink sufficient water to prevent dehydration.
  24. 24. The average adult drinks 2 to 3 liters of water per day. Normal lab values to know: Sodium: 135 - 145 mEq/L Potassium: 3.5 - 5.1 mE1/L Chloride: 98 - 107 mEq/L Bicarbonate: 22 - 29 mEq/LElimination In constipation, increase fluid to 3000 mL/day (unless contraindicated). Small frequent loose stools or seepage of stool are often indicative of a fecal impaction. Use transparent drainage bag initially for assessment of stoma and drainage. Avoid foods that cause odor, gas, diarrhea, or may block ileostomy. The majority of residents in nursing homes are incontinent but incontinence is not a normal sequela of aging.Pain Allow the client to rate the degree of pain (typically using a 10 point scale) and later to assess (and chart) degree of relief from pain relief measures. Self-control methods to manage pain: distraction, massage, guided imagery, relaxation, biofeedback, and hypnosis. Initiate pain relief before the pain becomes unbearable. Patient controlled analgesia (PCA) is effective at controlling pain and avoiding the peaks and valleys of nurse-administered narcotics; clients typically use less pain medication overall than clients receiving nurse-administered narcotics. Be sure to assess and monitor respiratory rate for client on PCA; have Narcan ready to reverse effects of the narcotic.Mobility There should be at least two inches between axilla and top of arm piece of crutch to prevent pressure on the brachial plexus. Prevent deformities and complications such as contractures, thrombophlebitis, and pressure ulcers by regularly turning and positioning the client in good alignment. Discontinue ROM exercises at point of pain. Use non-skid, rubber tips on crutches and canes to prevent slipping.