Health and Illness II Exam One Objectives

Define pain

"Unpleasant sensory and emotional experience associated with actual or potential tissue damage."

After surgery, an adolescent has a patient-controlled analgesia (PCA) pump that is set to allow morphine delivery every 6 minutes. Which statement indicates to the nurse that the family understand instructions about the PCA pump?

'She needs to push the PCA button whenever she needs pain medication.'

Data from pain assessments should include what?

- OLDCARTS - Comfort goal - Effect of discomfort on quality of life and function - Functional goal - Pain experience - History of pain and pain management strategies - Pertinent medical history with co-morbidities

Explain the nurses' role in pain management

-Administering medications -Drug and non-drug therapies -Assessing for pain (OLDCARTS) -Education

Define comfort

A desired state free from physiological discomfort, and common conditions that impair this state.

The nurse is caring for a client with signs of autonomic hyperreflexia. Which factor would the nurse consider as a possible cause?

Distended large intestine

Discuss ethical and legal issues related to pain management

Ethical issues revolving around drug abuse, end of life care, pain management, etc.

What are keys signs of a hip fracture?

Injured leg is shortened and externally rotated

Distinguish normal from abnormal findings of a physical assessment of musculoskelatal system.

Know what is NORMAL to find in a physical assessment of the musculoskeletal system, anything that deviates is abnormal Cap refill should be <2 seconds (veins) Pedal pulse should be +3 (artery) Eg: 5- Full ROM against gravity and full resistance (Full strength) NORMAL 4-Full ROM against gravity and moderate resistance (Weakness) 3- Full ROM against gravity but not resistance 2- Full ROM when gravity is eliminated 1-Muscle contraction seen 0-No muscle contraction ABNORMAL

Which position would the nurse use for placement of the affected extremity of a client who is recovering from an open reduction and internal fixation (ORIF) of a fractured hip?

Moderate abduction

Which condition would the nurse suspect in an emergency department client with C8 tetraplegia, blood pressure of 80/40 mm Hg, pulse of 48 beats per minute, and respiratory rate (RR) of 18 breaths per minute?

Neurogenic shock

What are interventions for compartment syndrome?

Notify HCP loosen constrictive dressings cut cast on one side prepare for fasciotomy

Explain the physical and psychological effects of unrelieved pain

Pain causes stress --> release of excessive of cortisol, catecholamine, and glucagon Pain --> activates the sympathetic nervous system.

Which clinical indicator is unique to a fat embolus?

Petechiae

Which intervention would the nurse perform first for a client with a spinal cord injury who is experiencing autonomic dysreflexia?

Place the client in sitting position.

What is a common complication caused by cuada equina?

Problems with urinary and bowel continence

A hospice client who has severe pain asks for another dose of oxycodone. Which consideration is the nurse's primary concern when responding to the client's request?

Reduce the client's pain.

A client with a fractured hip is placed in traction until surgery can be performed. Which goal would the nurse explain as the purpose of the traction?

Relieving muscle spasm and pain

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? Select all that apply. One, some, or all responses may be correct.

Spasticity Incontinence ✔️Flaccid paralysis Respiratory failure ✔️Lack of reflexes below the injury

Explain common complications associated with a spinal cord injury.

Spinal Shock Neurogenic Shock Autonomic Dysreflexia

A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. Which nursing action is most important when caring for this client?

Turning the client onto the side

Which pain scale would the nurse use when assessing a 4-year-old child?

Wong-Baker

What needs to be in the room prior to the patient returning from the OR? What position should the patient be in?

abduction pillow suction incentive spirometer Patient lower extremities should be in a abducted hips neutral ankles and knees extended position

The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct.

✔️Ask the client about the acceptable level of pain. Eliminate all activities that precipitate the pain. ✔️Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes.

Distinguish between different spinal cord injuries.

Primary injury- the cause of an injury, typically caused by trauma, damage is said and done cannot be reversed only managed/treated Secondary injury- an aftermath injury that comes after the primary injury (eg: swelling that results in increased nerve damage), this can be prevented Complete- whole spinal cord is injured, no purposeful movement below the injured vertebrae, full loss Incomplete- ability of the spinal cord to convey messages is not completely lost

What is Neurogenic shock?

- T6 and above *Decrease Spinal cord perfusion* Duration: -Lasts days- weeks -sympathetic gets wiped out (fight or flight) -parasympathetic takes over (rest and digest) Symptoms: -decreased BP -decreased HR -can cause dry skin And hypothermia Treatments: BP: -Fluids First -Medication (vasopressors) -Map push HR: -Medication (atropine) -pacemaker

A patient with a T injury requires what?

Almost always requires PRN suctioning due to increased secretions caused by inability to cough

A patient with a c5 and above injury requires what?

Almost always requires intubation and ventilation

What should you always ensure for a patient with a spinal cord injury?

Always ensure that the airway is patent (Airway, breathing, circulation)

Which type of treatment is the Buck extension?

Cutaneous traction

Interpret the data obtained from a pain assessment

Infant: -Look at faces (grimacing) -movements -sounds Non-verbal: -Writing or typing -Pointing at pain chart Sedated: -Vitals

An older adult fell at home and fractured the left hip. Which clinical indicator would the emergency department nurse identify as typical with a fractured left hip?

Left leg is noticeably shorter than the right

Should you elevate with compartment syndrome? Should you use ice?

No, you should NEVER elevate and NEVER use ice.

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem?

Urinary tract infections

What are possible complications of traction?

infection impaired skin integrity (risk for pressure ulcers) pain incontinence immobility

What is compartment syndrome?

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

What is Autonomic dysreflexia?

- T6 and above *Noxious stimuli* -can happen often/ is chronically acute on and off AFTER spinal shock is resolved Common causes: -retention of urine -retention of stool -stimulus below level of injury (socks too tight, wrinkled blankets, etc) Symptoms: -Elevated BP (hypertension) -Decreased HR (bradycardia) -Headache -vasoconstriction -*HIGH BLOOD PRESSURE LOW HEART RATE* Indications: -headache due to high bp Treatments/ interventions: - First Raise head of the bed 40 degrees or higher -Then find cause (bladder scan, distention? look for stimuli such as tight socks or wrinkled sheets. -urinary catheter every 4-6 hours -BP medication/ increased fluids/ meds to reduce fluid retention -medication for bowel/ fiber/ daily suppository around the same time everyday - Call provider if it has not worked *medical emergency*

Describe effective pain management techniques

-Medication (opiod and non-opioid) -Heating pad -PT/OT -nonpharmacological therapies

Assess the changes in the musculoskelatal system related to injury and disease.

-Reduction in muscle mass -atrophy -contracture of joints -bone demineralization -Reduced ROM Infancy and childhood- growth and development Aging: • thinning of vertebral disks • shortening of the spinal column • onset of kyphosis with spinal column compression • bone density decreases and becomes brittle • cartilage becomes rigid and fragile • loss of resilience and elasticity of ligaments • muscle mass and tone reduce

Describe the significance of results and nursing care related to the musculoskeletal system.

-Reduction of bone (put into alignment) -immobilization -restore function -prevent further injury

Describe nursing management of nausea and vomiting

-Suctioning -Around the clock treatments for chronic severe pain -Assess vital signs (hypovolemia main risk of prolonged vomiting: check follow BP, high HR, and tenting of skin turgor) -Limit food intake, give bland meals -Patient positioning -Premedicate patients 30mins before procedure or meds that cause nausea

What is true about bucks traction?

-Use for 24-48 hours -Used for painful muscle spasms, used to reduce them -Always maintain perfusion and skin integrity when using -Standard weight orders are less than 10 pounds

Explain common complications associated with a fracture and healing fractures.

-compartment syndrome high risk in fractures (hip) • Swelling • Pain • Deformity • Decrease functional use/Pulse • Bruising • Muscular Rigidity • Crepitus •Numbess/Tingling

Compartment syndrome 5 Ps

-pain not received by pain meds -pallor -pulselessness -paresthesia: late/ominous sign of damage -paralysis -pressure -if CS is suspected call immediately for evaluation

Understand the anatomy and physiology of the spinal cord.

Anterior cord(front): descending motor neurons -crosses over at the base of the brain Posterior cord(back): ascending sensory neurons -light touch, proprioception(how one body part reacts to another), vibration -crosses over at the base of brain Lateral cord: carries ascending sensory neurons, pain, temperature, crude touch -crosses over at the entry point to the spinal cord

What is spinal shock?

Any SCI Swelling Temporary concussion of deep tendon reflexes - *loss of sensory and deep tendon reflexes* -activates sympathetic nervous system (fight or flight) -all feeling/ reflexes can come back Duration: Can last days- weeks Symptoms: -Increased HR Treatments: -PT -Medication

An abdominal cholecystectomy is performed on a client with gangrene of the gallbladder. During the first 24 hours postoperatively, when will analgesics be administered?

As prescribed by the health care provider

Which nursing intervention is correct for a client in skeletal traction?

Assess the pin sites at least every shift and as needed.

Define neuropathic pain

Damage to peripheral nerves Symptoms: -Numbing -Hot -Burning -Shooting -Stabbing -Sharp -Electric Shock-like

Define nociceptive pain

Damage to somatic or visceral tissue, superficial or deep Symptom for superficial: -sharp -burning -prickly Symptoms for deep: -aching -throbbing

Unrelieved pain decreases what?

Decrease in: •Insulin •Testosterone • Weight • Immune Function • Lung Tidal Volumes • Lung Capacity • Mobility • Peristalsis • Work • Activities

The nurse finds the client on the floor, crying for help, with signs of a hip fracture. Which action would the nurse take first?

Immobilize the affected extremity.

Unrelieved pain increases what?

Increase in: • Heart Rate • Respiratory Rate • Post op blood loss • Coagulation • Fear • Anger • Depression • Anxiety

Obtain significant subjective and objective assessment related to the musculoskeletal system from a patient.

Subjective data: what the patient verbally says about pain Objective data: xray, ROM, CT or MRI scans, etc.

What is a total hip replacement?

Surgery to restore a damaged hip to full function. During the surgery, a plastic lining is fitted into the acetabulum to restore a smooth surface. The head of the femur is removed and replaced with a metal ball attached to a metal shaft that is fitted into the femur.

Which methods qualify as alternative therapies for pain? Select all that apply. One, some, or all responses may be correct.

✔️Prayer ✔️Hypnosis Medication ✔️Aromatherapy ✔️Guided imagery