Ch 39,40,42,43

Use the nursing process to plan and implement care for dying

Assessing: - Patient/family knowledge - Patient/family attitudes and feeling about death and the dying process - Advanced directives - Religious/Cultural beliefs - Ability to cope - Resources - Physiologic, Psychologic, Spiritual needs How much does the pt know about is going on? How good are they coping? What strategies are they using? Do they have family involved? Do they need hospice? What can we do to make the situation better? Focus on signs of death for assessment. Diagnosing - Loss and Impending Death -- Caregiver Role Strain -- Ineffective Coping -- Hopelessness Planning and Identifying Outcomes - Demonstrate freedom to express to feelings, needs, fears, and concerns - Identify and use effective coping strategies - Make decisions that reflect personal values - Report sufficient relief of pain Implementing - Communication - Establish trust and therapeutic relationship - Explain the patient's condition and treatment. - Teach self-care and promoting self-esteem. - Teach family members to assist in care. - Meet the needs of the dying patient. - Meet family needs. · Nursing Interventions - Dying patients' Bill of Rights (They have right to participate, make decisions, be with someone, to not die alone, be free from pain (comfort care) - DO NOT provide false reassurance p. 1704 do not say " it is going to be okay" - Explaining the patient's condition and treatment - Teaching self-care keep them independent as much as possible, like brushing teeth or feed themselves. - Promoting self-esteem try to make them feel better about themselves, talking about their life and all of the great things they have done - Teaching family members to assist in care include them in care - Meeting the needs of a dying patient ---- Physiological, psychological, intimacy, spiritual Physiological: pain, food, body needs. Let them sit, walk around. Comfort care. Think Maslow Psychological: mind. Being there w pt, maybe they don't have family. Ask about how they are feeling. Intimacy: having someone there. Allowing family members to be in the room w them. Encourage to talk, hug, lay w them. Spiritual: make sure to call churches, have pastors come in and meet with them. o Meeting the needs of the family take care of the family as well. When was the last time you ate? Have you showered? o Providing post-mortem care -- Caring for the body clean the body up, put pt's belongs away and put tags on body and things. Be aware of basics. -- Caring for the family take care of pt's family after death. Let family sit w the body as long as they want to (within reason) -- Caring for oneself as the nurse As a nurse you will likely experience death, it is a difficult situation. Make sure you are dealing with it appropriately. ** Hearing is the last thing that goes away when dying. Patient may be close to death or coma, but most likely still hear you. Encourage family to talk to patient. Be mindful about what you are saying.

Assess, plan, implement, and evaluate nursing care related to select nursing diagnoses involving fluid, electrolyte, and acid-base imbalances.

Assessment: - Skin turgor (elasticity) - Tongue turgor - Moisture and oral cavity - Tearing and salivation - Appearance of skin and skin temperature - Facial appearance - Edema (excessive accumulation of interstitial fluid) - Body temperature - Pulse - Respirations - Blood Pressure - Include assessment of the skin and mucous membranes, vital signs, and a neurologic assessment, as well as identification of relative symptoms or conditions such as excessive thirst, nausea, vomiting, diarrhea, draining wounds, or other fluid losses. - Fluid Intake and Output - Daily Weights: the record of a patient's daily weight may more accurately depict fluid balance status, due to possible numerous sources of inaccuracies in fluid intake and output measurement. Weigh the patient at the same time every day. - Lab Studies: complete blood count, Assess : - Usual patterns of fluid intake - Usual pattern of fluid elimination - Patient's evaluation of hydration status - History of disease process - Medication/nutrition history - Fluid, electrolyte, and acid-base imbalances and contributing factors examples: How much do you drink a day? How often do you urinate? Do you have kidney/heart diseases? Do you have diabetes? - Assessment - color, turgor, looking at intake and output, looking at mucous membranes, mental status/level of consciousness, edema, vital signs Diagnosing - Excess Fluid Volume (fluid restrictions/limits) --- Renal failure, decreased cardiac output, excessive IV infusion/fluid intake, excessive sodium intake - Deficient Fluid Volume (increase fluid intake) --- Inability to obtain or swallow fluids (debilitation, oral pain), extremes of age, vomiting, diarrhea, burns, excessive use of laxative, excessive diaphoresis, fever - Risk for Deficient Fluid Volume --- Inability to access fluids, extremes of age, insufficient knowledge about fluid needs - Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease, dysfunctions of the heart, and certain cancers. - Fluid volume deficits may result from decreased intake or increased excretion of fluids as well as fluid shifts. - In addition, fluid and electrolyte deficiencies may be related to situations involving strenuous exercise, extreme heat or dryness, and conditions that increase the metabolic rate, such as fever. INTERVENTIONS: I/Os Dietary Planning - Include foods that help to resolve the fluid or electrolyte imbalance and that are acceptable to the patient. For example, for fluid volume deficit, increase foods with high water content (e.g., citrus fruit, melons, celery); for hypokalemia, increase foods with high potassium content (e.g., bananas, citrus fruits, apricots, melons, broccoli, potatoes, raisins, lima beans); and for hypernatremia, avoid foods high in sodium (e.g., processed cheese, lunch meats, canned soups and vegetables, salted snack foods) and eliminate the use of table salt. Modifying fluid intake - Depending on the nature of the fluid or electrolyte imbalance, a patient's fluid intake may need to be increased, decreased, or modified in terms of types Teaching Administering Intravenous (IV) Fluid Therapy - A relatively common form of therapy for handling fluid disturbances is the use of infused IV solutions. The physician or other licensed health care professional with prescriptive privileges is responsible for prescribing the type and volume of solution to be administered. The nurse is responsible for initiating, monitoring, and discontinuing the therapy. Nursing interventions to prevent or correct fluid, electrolyte, and acid-base imbalances include dietary modification, modification of fluid intake, medication administration, IV therapy, blood and blood products replacement, and administration of PN. OUTCOMES: Nursing care supports the following expected outcomes. The healthy adult patient will: - Maintain an approximate balance between fluid intake and fluid output (average about 2,500 mL fluid intake and output over 3 days) - Maintain a urine specific gravity within normal range (1.005 to 1.030) - Practice self-care behaviors to promote fluid, electrolyte, and acid-base balance; maintain adequate intake of fluid and electrolytes; and respond appropriately to the body's signals of impending fluid, electrolyte, or acid-base imbalance. REMEMBER : - Nursing assessment related to fluid, electrolyte, and acid-base balance should include a nursing history, physical assessment, fluid intake and output, daily weights, and laboratory studies. - Nursing interventions to prevent or correct fluid, electrolyte, and acid-base imbalances include dietary modification, modification of fluid intake, medication administration, IV therapy, blood and blood products replacement, and administration of PN. - Patient education is essential for independence in self-care related to fluid, electrolyte, and acid-base imbalance. - The nurse evaluates the effectiveness of a care plan to promote fluid, electrolyte, and acid-base imbalances by checking whether the patient has met the individualized patient goals specified in the plan. - Before nursing care is terminated, the patient and family should be able to independently promote fluid, electrolyte, and acid-base balance.

Electrolytes

minerals that carry electrical charges that help maintain the body's fluid balance Electrolytes are substances that are capable of breaking into particles called ions. - An ion is an atom or molecule carrying an electrical charge. - Some ions develop a positive charge and are called cations. The major cations in body fluid are sodium, potassium, calcium, hydrogen, and magnesium. - Other ions develop a negative charge and are called anions. The major anions in body fluid are chloride, bicarbonate, and phosphate. - These charged particles are the basis of chemical interactions in the body necessary for metabolism and other functions. - Molecules in the body that remain intact, without a charge, are called nonelectrolytes. In the human body, urea and glucose are examples of nonelectrolytes.

Summarize the mechanisms involved in maintaining physiologic and psychological homeostasis.

stress - is a condition in which the human system responds to changes in its normal balanced state. - Stress results from a change in a person's internal or external environment that is perceived as a challenge, a threat, or a danger. The major sources of stress in our society arise from interpersonal relationships and performance demands rather than from actual physical threats STRESSORS- is anything that is perceived as challenging, threatening, or demanding that triggers a stress reaction. Stressors themselves are neither positive nor negative, but they can have positive or negative effects as the person responds to change. internal vs external - INTERNAL: e.g., an illness, a hormonal change, or fear - EXTERNAL: e.g., loud noise or cold temperature physiologic (body) vs. psychosocial (mind) - Stressors can be physiologic or psychosocial. A physiologic stressor may cause psychosocial stress, and vice versa. - PHYSIOLOGIC: Physiologic stressors have both a specific effect and a general effect. The specific effect is an alteration of normal body structure and function. The general effect is the stress response. Primary physiologic stressors include chemical agents (drugs, poisons), physical agents (heat, cold, trauma), infectious agents (viruses, bacteria), nutritional imbalances, hypoxia, and genetic or immune disorders. - PSYCHOSOCIAL: The environment, interpersonal relationships, or a life event can lead to the stress response if a person does not have the resources to adequately respond to the perceived or actual stressor. EXAMPLES: - Accidents, which cause stress for the victim, the person who caused the accident, and the families of both - Stressful or traumatic experiences of family members and friends - Horrors of history, such as Nazi concentration camps, the dropping of the atomic bomb on Hiroshima, the September 11, 2001 or Orlando Pulse nightclub (2016) terrorist attacks, or any of the school shootings of 2018 (eg. Parkland, FL). - Fear of aggression or mutilation, such as muggings, rape, shootings, and terrorism - Events of history that are brought into our homes through television and the internet, such as wars, earthquakes, violence in schools, and civil unrest - Rapid changes in our world and the way we live, including changes in economic and political structures, and rapid advances in technology adaptation - The change that takes place as a result of the response to a stressor - When a person is in a threatening or otherwise stressful situation, immediate responses occur. Those responses, which are often involuntary, are called coping responses. - Adaptation is necessary for normal growth and development, the ability to tolerate changing situations, and the ability to respond to physical and emotional stressors. homeostasis - To maintain health, the body's internal environment must remain in a balanced state. Various physiologic mechanisms within the body respond to internal changes to maintain relative constancy in the internal environment o Physiological homeostasis p. 1661 primarily controlled by autonomic nervous system and endocrine system. Release hormones and prepare us to respond to stress. o Psychological homeostasis p. 1663 use of coping or defense mechanisms. Think about the connection to Maslow's Hierarchy of Needs.

Identify ethical and legal issues in end-of-life care, including advance directives, physician orders, assisted suicide, and euthanasia.

- Advance directive: living will vs power of attorney - Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. - what you want to happen or not to happen at the event of death, instructions. Things like maybe you don't want a feeding tube. Your wishes. - A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. - you are naming someone who can take over if you are not able to. For example in a coma. Your children make decisions for you. Giving someone else power over you. POLST form (A Physician Order for Life-Sustaining Treatment form) - Doctors order, a list is created about what patient wants and doesn't want to happen. Cancer patients. Think of it as for more in the hospital. - is a medical order indicating a patient's wishes regarding treatments commonly used in a medical crisis. Because it is a medical order, a POLST form must be completed and signed by a health care professional and cannot be filled out by a patient. DNR - Do Not Resuscitate (DNR) order, or No Code, on the medical record of a patient if the patient or surrogate has expressed a wish that there be no attempts to resuscitate the patient. A Do Not Resuscitate order means that no attempts are to be made to resuscitate a patient whose breathing or heart stops. - If there is no DNR, then you must do CPR. No breathing tubes. No saving, can be hard ethically. Do Not Intubate (DNI) - No breathing tube, but CPR is okay. Comfort measures only - patients just want medications or things that will make them feel comfortable. No breathing tubes. - Whereas some patients may want aggressive life-sustaining treatment and such treatment may be medically beneficial, other patients may be at a point in their illness at which they choose to terminate all life-sustaining measures and allow the disease to progress naturally to death. - which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. Euthanasia literally means "good dying." Active euthanasia is taking specific steps to cause a patient's death, while passive euthanasia is defined as withdrawing medical treatment with the intention of causing the patient's death. In other words, active euthanasia is doing something to end a patient's life, whereas passive euthanasia is not doing something to preserve a patient's life. In assisted suicide (which could be considered a form of active euthanasia), the clinician provides the patient with the means to cause his or her own death (e.g., a prescription for a lethal dose of barbiturates). In active euthanasia, the clinician acts directly to cause the death of the patient (e.g., administers a lethal dose of medication).

TEACHING PATIENTS TO USE AN INCENTIVE SPIROMETER

- Assist the patient to an upright or semi-Fowler's position if possible. - Remove dentures if they fit poorly. - Assess for pain. Administer pain medication, as prescribed, if needed. If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting. - Demonstrate how to steady the device with one hand and hold the mouthpiece with the other hand. Instruct the patient to exhale normally and then place lips securely around the mouthpiece. - Instruct the patient not to breathe through the nose. Use a nose clip if necessary. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose (a nose clip may be used). Note the movement of the inhalation indicator on the spirometer. - When the patient cannot inhale anymore, the patient should hold his or her breath and count to three. Check position of gauge to determine the progress and level attained. - Instruct the patient to remove the lips from the mouthpiece and exhale normally. If the patient becomes lightheaded during the process, tell him or her to stop and take a few normal breaths before resuming incentive spirometry. - Encourage the patient to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. Rest in between breaths as necessary.

Explain six factors that affect loss, grief, and dying.

- Developmental considerations - age related, Kids do not understand death, esp younger ages. Can still feel it, but do not understand. As we are older, we have had losses, as adults you feel it and understand it more fully. - Children do not understand death on the same level as adults do, but their sense of loss is just as great. Both terminally ill children and their siblings are likely to talk about and ask questions about death in an attempt to understand it. Terminally ill children require parental love and support as well as social interaction with other children. Death of a parent or another significant person can retard a child's development or may cause the child to regress developmentally. Children need to go through the same grief reactions as adults to accept such a loss and maintain emotional well-being. Family - Family roles have an important effect on a person's reactions to and expressions of grief. For example, the eldest sibling may feel a need to "be strong" and therefore may not grieve openly; a person who loses a spouse may display the same type of behavior to "protect the children." - The death of a child is a devastating experience for the family. The family needs time to accept the reality of the situation, opportunities to talk and to be listened to, and the experience of being able to express themselves behaviorally in a nonjudgmental environment. For example, the family of a terminally ill child may express feelings of guilt by wondering if they were responsible for the impending death. A sibling may suppress a guilt feeling for having wished the ill child (or a parent) dead. - Can be loss of anything. A family member (who provided support and financial stuff, now have no money). Can also be a family member losing a job bc it affects the whole family. Socioeconomic factors - Related to social status or money. Ex: a family lost a family member bc they didn't have insurance to deal with it. - A bereaved family may suffer more acutely if there is no health or life insurance or pension after the death of the family provider. Such families face not only the loss of a loved one, but also an economic loss that may further disrupt family life. Older adults especially may be placed in a difficult position because the death of a spouse may result in the decrease or even elimination of a source of retirement income for the surviving spouse. This reduction in income may lead to loss of home, community, and support systems. Cultural, Biological Sex, and Religious Influences - Culture influences a person's expression of grief. In many families in the Western culture, grief is a private matter shared only with the family. As such, many people internalize their feelings of grief and may not express their feelings of loss to others. On the other hand, cultural background may necessitate that the patient's and family's public display be emotional and distressed, with loud weeping and moaning. - Although biological sex roles have become less differentiated in the past few decades, male and female reactions to death may differ. Whereas men are often expected to be stoic and not cry in public, women may be judged as "cold" if they do not grieve publicly. A widow who has a job may not be as emotionally distraught as a woman who needed her husband for financial and other support. Likewise, a widower who has not taken care of the children or the house may view the future more bleakly than a man who has cooked meals and changed diapers. Some ethnic traditions may be ingrained in certain people. For example, the woman may be expected to be weak and need support, whereas the man may be expected to be emotionally supportive. This varies from culture to culture and from person to person. - Faith and religious practices play an important role in the expression of grief and may provide comfort and solace to the person experiencing loss. However, some people may blame God for their suffering and the death of their loved one and turn away from God. Many people who have put spiritual matters in the background of their lives have found death to be an impetus for a return to earlier practices of religion. The thought of death also invites many to contemplate life's big questions: Is there life after death? Is there a supreme being? And if there is a supreme being, where do I stand in relationship to that being? What is the ultimate source of meaning in my life? Cause of Death - ex: Cancer: you know it is going to happen, kind of prepared. Car accident: sudden. - Many deaths are sudden and involve shock as well as normal grieving in the survivors. Death from disease may generate several types of responses, including the belief that the death is a punishment (e.g., when AIDS was first diagnosed in homosexuals and drug users); terror and panic (e.g., when people are reminded of the devastation caused by plagues of earlier centuries); and guilt (e.g., when family and friends believe that they could have prevented the death). - Accidental death is often associated with feelings of bad luck. The guilt response can be enormous, especially when children die as the result of an accident. Death while defending a country usually is viewed by most of society as honorable and necessary. Violent deaths occur daily, especially in larger cities. Suicide accounts for a great number of violent deaths; in fact, among teenagers, it has become a major concern. It is also believed that many accidental deaths are actually suicides.

KEY TERMS

- Stress is a part of everyone's life, and a person's responses to stress are unique. - Adaptation is the change that takes place as a response to a stressor. - Homeostasis results when physiologic mechanisms within the body respond to internal changes to maintain relative constancy in the internal environment. - The local adaptation syndrome (LAS) is a localized body response to stress involving only a specific body part rather than the whole body. - The general adaptation syndrome (GAS) describes the body's general response to stress, involving the alarm reaction (fight-or-flight response), the stage of resistance, and the stage of exhaustion. - Anxiety is the most common response to stress and is different from fear, which is a response to a known threat. - The various levels of anxiety are mild anxiety, moderate anxiety, severe anxiety, and panic. - Defense mechanisms are unconscious reactions to stressors. - Long-term stress is a serious threat to physical and emotional health, and increases the risk for disease or injury. - Developmental stress and situational stress both require adaptive responses, which are influenced by personal factors. - Burnout is the exhaustive stage of anxiety that can occur when nurses become overwhelmed and develop symptoms of stress. - The nursing history can assist nurses to identify stressors that patients are experiencing as well as their reactions to the stress. - Nursing diagnoses may reflect stress as the cause of the problem or the etiology of the problem. - Exercise, rest, and good nutrition are important components in nurses' teaching about stress reduction. - The occurrence of a crisis requires intervention to help people regain equilibrium.

Describe age-related differences that influence the care of patients with oxygenation problems. OLDER ADULTS

-Bony landmarks are more prominent due to loss of subcutaneous fat. -Kyphosis contributes to appearance of leaning forward. -Barrel chest deformity may result in increased anteroposterior diameter. -Tissues and airways become more rigid; diaphragm moves less efficiently. -Older adults have an increased risk for disease, especially pneumonia. Decreased Gas Exchange and Increased Work of Breathing - Decreased elastic recoil of the lungs - Expiration requiring use of accessory muscles - Fewer functional capillaries and more fibrous tissue in alveoli - Decreased skeletal muscle strength in thorax - Reduction in vital capacity and increase in residual volume Decreased Ventilation and Ineffective Cough - Less air exchange; more secretions remain in lungs - Drier mucous membranes - Altered pain sensation - Different norms for body temperature; fever may be atypical - Greater risk for aspiration due to slower gastric motility - Impaired mobility and inactivity, effects of medication Decreased CO and Ability to Respond to Stress - Reduction in the elasticity of the heart's tissues - Heart muscle becomes less efficient—working harder to pump the same amount of blood through the body. - Progressive atherosclerosis (fatty buildup or plaques, thickening) in arterial walls and loss of elasticity - Capillary walls thicken slightly, leading to a slower rate of exchange of gases, nutrients, and waste.

Describe age-related differences that influence the care of patients with oxygenation problems. INFANTS

-Lungs are transformed from fluid-filled structures to air-filled organs. -The infant's chest is small, airways are short, and aspiration is a potential problem. -Respiratory rate is rapid and respiratory activity is primarily abdominal. -Synthetic surfactant can be given to the infant to reopen alveoli. -Crackles heard at the end of deep respiration are normal.

Describe age-related differences that influence the care of patients with oxygenation problems. CHILDREN

-Some subcutaneous fat is deposited on the chest wall, making landmarks less prominent. -Eustachian tubes, bronchi, and bronchioles are elongated and less angular. -The average number of routine colds and infections decreases until children enter daycare or school. -Good hand hygiene and tissue etiquette are encouraged. -By the end of late childhood, the immune system protects from most infections. -A child's blood vessels widen and increase in length over time. The blood pressure increases over time, reaching the adult level in adolescence.

KEY CONCEPTS

-The potential for loss, grief, and death exists at any stage of life. This is especially true for people experiencing altered health and for members of their family. -The nurse is often the person providing support and care when loss or death occurs. To provide effective care, nurses must have accepted their own feelings about death and understand the stages of grieving and dying. -Loss occurs when a valued person, object, or situation is changed or becomes inaccessible so that its value is diminished or removed. This includes actual loss, perceived loss, and anticipatory loss. -Grief is an internal emotional reaction to loss caused by separation as well as loss caused by death. Mourning is the actions and expressions that make up the outward expressions of grief. -Engel's six stages of grief are: (1) shock and disbelief, (2) developing awareness, (3) restitution, (4) resolving the loss, (5) idealization, and (6) outcome. -The Uniform Determination of Death Act (1981) defines death as either (1) irreversible cessation of all functions of circulatory and respiratory systems or (2) irreversible cessation of all functions of the entire brain. -A good death is one that allows a person to die on his or her own terms, relatively free of pain, with dignity, and free from avoidable distress and suffering for patients, families, and caregivers. -According to Kübler-Ross, the five stages of dying are denial, anger, bargaining, depression, and acceptance. -Patients must be allowed to go through the stages of the grieving process and must be supported in their decision making. -Palliative care means taking care of the whole person—body, mind, and spirit, heart and soul. The goal of palliative care is to give patients with terminal illness the best quality of life they can have by the aggressive management of symptoms. -Hospice care is care provided for people with limited life expectancy, often in the home. -Advance directives can minimize difficulties by allowing people to state in advance what their choices would be for health care should certain circumstances develop; they include living wills and a durable power of attorney. -Physician Orders for Life-Sustaining Treatment (POLST) and Medical Orders for Life-Sustaining Treatment (MOLST) forms are medical orders indicating a patient's wishes regarding treatments; they are commonly used in a medical crisis. -Euthanasia literally means "good dying." Active euthanasia is taking specific steps to cause a patient's death. Passive euthanasia is defined as withdrawing medical treatment with the intention of causing the patient's death. -In the United States, physician-assisted suicide is legal only in some states. The American Nurses Association has issued position statements stating that assisting in suicide and participating in active euthanasia are in violation of the Code for Nurses, the ethical traditions and goals of the profession, and its covenant with society. -Many factors, including age, family relationships, socioeconomic position, and cultural and religious influences, affect a person's reaction to loss and expression of grief. -Focused assessment for those experiencing loss, grief, and dying is directed toward determining the adequacy of the patient's and family's knowledge, perceptions, coping strategies, and resources. -The data the nurse collects about how a patient or the patient's caregivers are responding to an actual or impending loss or impending death may support nursing diagnoses such as Death Anxiety, Grieving, and Hopelessness. -The patient and the family should take an active role in planning for care. -Nursing interventions to meet the needs of dying patients include meeting bio-psycho-social and spiritual needs as well as the needs of the family and significant others. -When a patient dies, the nurse's responsibilities include caring for the patient's body, caring for the family, and discharging specific legal responsibilities. -The nursing care plan for dying patients is effective if patients meet the outcome of a comfortable, dignified death, and family members resolve their grief after a suitable time of mourning and resume meaningful life roles and activities.

Develop nursing diagnoses that correctly identify problems that may be treated by independent nursing interventions.

1. Ineffective airway clearance - Asthma, COPD, thick mucus, lot of secretions, trouble coughing it up, weak cough 2. Impaired gas exchange - Smokers, people working with asbestos, someone who has been sick for awhile may have impaired gas exchange, short of breath, sit in tripod position (sometimes), look like they're struggling to breathe, possibly cyanotic, may have some wheezing or crackles, increased respiratory rate 3. Ineffective breathing pattern - Breathing shallow, or too fast. Anxiety. Hyperventilation. EXAMPLES Ineffective Airway Clearance r/t Fatigue; retained secretions; a 20-year history of COPD, with recent development of pneumonia AEB • "I never feel as though I am getting enough air." • Thick, yellow secretions • Pale skin with circumoral cyanosis; respiratory rate is 40 breaths/min and shallow. Coarse crackles are auscultated bilaterally. • Cannot sit quietly in chair or on bed. • Ineffective cough Impaired Gas Exchange r/t Smokes one pack of cigarettes per day; works with asbestos in auto factory; has had a cold for 7 days AEB • Using pursed-lip breathing • Sitting hunched forward with overbed table supporting arms. • Altered blood gases show respiratory acidosis. • Reports shortness of breath for 1 week. Ineffective Breathing Pattern r/t Anxious about results of cardiac catheterization and possible cardiac surgery AEB • Hyperventilating, tachypneic (40 breaths/min) • "I have a tingling feeling in my fingers." • "I can't catch my breath and I can't lie down in bed."

Describe physiologic, psychological, and spiritual care of a dying patient and family.

A good death is one that allows a person to die on his or her own terms, relatively free of pain, and with dignity. It is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' families' wishes; and reasonably consistent with clinical, cultural, and ethical standards Box 43-1 Providing care to facilitate a good death Although death occurs at any age, the probability of death increases as a person grows older. Guidance for all health care providers in providing excellent care for dying patients of any age. - The care of the dying patient should be guided by the values and preferences of the individual patient. Independence and dignity are central issues for many dying patients, particularly in older adults. Maintaining control and not being a burden can also be relevant concerns. - Palliative care of dying patients is an interdisciplinary undertaking that attends to the needs of both patient and family. - Care for dying patients should focus on the relief of symptoms, not limited to pain, and should use both pharmacologic and nonpharmacologic means. - Physicians and other health care professionals, at all levels of training, should receive in-depth, insightful, and culturally sensitive instruction in the optimal care of dying patients. - Adequate funding for research on the optimal care of dying patients is essential to improving end-of-life care. Developing trusting nurse-patient and nurse-family relationships - In nursing we also have to care for the family. P. 1688. We are trying to make the pt comfortable and feel as good as possible. Taking care of them. Take care of mental, physical, spiritual needs. Make it a better process. COMFORT is key here. - Make sure to involve families as much as possible and help w the care of the pt. let them spend as much time as they want to w family member. - Health care personnel should be available to discuss the patient's condition with family members and should offer support and care as the family begins the grieving process

Plan, implement, and evaluate nursing care related to select nursing diagnoses involving oxygenation problems.

A range of 95% to 100% is considered normal SpO2; - values ≤90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error. When caring for patients with an alteration in oxygenation, nursing measures support the following general expected outcomes. The patient will: - Demonstrate improved gas exchange in the lungs by an absence of cyanosis or chest pain and a pulse oximetry reading more than 95% - Relate the causative factors, if known, and demonstrate a method of coping with these factors - Preserve cardiopulmonary function by maintaining an optimal level of activity - Demonstrate self-care behaviors that provide relief from symptoms and prevent further cardiopulmonary problems. Precautions for oxygen administration - Avoid open flames in the patient's room. - Place "no smoking" signs in conspicuous places. - Check to see that electrical equipment in the room is in good working order. - Avoid wearing and using synthetic fabrics (builds up static electricity). - Avoid using oils in the area (oils ignite spontaneously in oxygen) Administering Cardiopulmonary Resuscitation (CAB) Chest Compressions: Check the pulse. If the victim has no pulse, initiate chest compressions to provide artificial circulation. Airway: Tilt the head and lift the chin; check for breathing. The respiratory tract must be opened so that air can enter. Breathing: If the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1 second each. Defibrillation: Apply the AED as soon as it is available

Defense mechanisms

Coping Mechanisms Anxiety is often managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. Many coping behaviors are learned, based on a person's family, past experiences, and sociocultural influences and expectations. As illustrated in the list that follows, coping behaviors may be positive or negative in terms of how they affect health. Typical coping behaviors include the following: - Crying, laughing, sleeping, cursing - Physical activity, exercise - Smoking, drinking - Lack of eye contact, withdrawal - Limiting relationships to those with similar values and interests Moderate, severe, and panic levels of anxiety are greater threats and involve more complex coping mechanisms as the person strives to reduce the stress and anxiety. Coping mechanisms often used at higher levels of anxiety are categorized as task-oriented reactions. Task-oriented reactions involve consciously thinking about the stress situation and then acting to solve problems, resolve conflicts, or satisfy needs. These reactions include attack behavior, withdrawal behavior, and compromise behavior. Attack behavior occurs when a person attempts to overcome obstacles to satisfy a need; it may be constructive, with assertive problem solving, or destructive, with feelings and actions of aggression and hostility. Withdrawal behavior involves physical withdrawal from the threat, or emotional reactions such as admitting defeat, becoming apathetic, or feeling guilty and isolated. Compromise behavior is usually constructive, often involving the substitution of goals or negotiation to partially fulfill needs. Defense Mechanisms - Other unconscious reactions to stressors, called defense mechanisms, often occur. These mechanisms protect a person's self-esteem and are useful in mild to moderate anxiety. When extreme, however, they distort reality and create problems with relationships examples: - compensation : a student who has difficulty with academics may excel in sports - denial - displacement : an employee who is angry with a coworker kicks a chair - dissociation - introjection : an older sibling telling younger one to not talk to strangers bc of parents values - projection : a person denies sexual feelings for a coworker and then accuses of sexual harassment - rationalization - reaction formation : a woman is attracted to husbands bestfriend but is always rude to him - regression - sublimation - undoing

Compare and contrast developmental and situational stress, incorporating the concepts of physiologic and psychosocial stressors.

Developmental Stress: occurs as a person progresses through the normal stages of growth and development. - Age related (toddler, middle aged person) one time thing. - Developmental stress occurs as a person progresses through the normal stages of growth and development from birth to old age examples: -The infant learning to trust others -The toddler learning to control elimination -The school-aged child socializing with peers -The adolescent striving for independence -The middle-aged adult accepting physical signs of aging -The older adult reflecting on past life experiences with satisfaction Situational Stress: can occur at any time. - Can happen any time, can happen multiple times throughout life. Examples: illness, marriage, divorce, going to college. Can be good or bad stress. - Situational stress is different from developmental stress. It does not occur in predictable patterns as a person progresses through life. Situational stress can occur at any time, although the person's ability to adapt may be strongly influenced by his or her developmental level. examples -Illness or traumatic injury -Marriage or divorce -Loss (of belongings, relationships, family member) -New job -Role change

Discuss the effects of short-and long-term stress on basic human needs, health and illness, and the family.

Effects of Stress on Basic Human Needs Physiologic Needs - Change in appetite, activity, or sleep - Change in elimination patterns - Increased pulse, respirations, blood pressure Safety and Security -Feels threatened or nervous -Uses ineffective coping mechanisms -Is inattentive Love and Belonging - Is withdrawn and isolated - Blames others for own faults - Demonstrates aggressive behaviors - Becomes overly dependent on others Self-Esteem - Becomes a workaholic - Exhibits attention-seeking behaviors Self-Actualization - Refuses to accept reality - Centers on own problems - Demonstrates lack of control health and illness - Stress in healthy person may promote health and prevent illness. Stress can make illness worse and illness can cause stress. - Example. Smoking causes them stress and they quit smoking. Or pregnant and decides to start new healthy habits. family - The stress that affects an ill person also affects the person's family members or significant others. When the family is viewed as a system, the behavior of the individual is influenced by family, and any alterations in the individual's behavior in turn affect the family. - Stressors for the family include changes in family structure and roles, anger and feelings of helplessness and guilt, loss of control over normal routines, and concern for financial stability. - If you have a family member who has a chronic illness, or someone in family lost a job, stress affects entire family.

Differentiate the physical and emotional responses to stress, including local adaptation syndrome, general adaptation syndrome, mind-body interaction, anxiety, and coping and defense mechanisms.

Physiologic homeostasis - The autonomic nervous system and the endocrine system primarily control homeostatic mechanisms. Involved to a lesser degree are the respiratory, cardiovascular, gastrointestinal, and renal systems. These mechanisms are self-regulating, organized, and coordinated; they occur without conscious thought, and defend against change to the body's internal environment. On a simple level, these self-regulating mechanisms are like a thermostat regulating a furnace. When the temperature in a house falls below the preset temperature on the thermostat, the thermostat turns on the furnace, which heats the house to the desired temperature and then shuts off. This is a classic example of a negative feedback system, which is the primary means by which homeostasis is maintained local adaptation syndrome (LAS) - is a localized response of the body to stress. It involves only a specific body part (such as a tissue or organ) instead of the whole body. The stress precipitating the LAS may be traumatic or pathologic. LAS is a primarily homeostatic, short-term adaptive response. Although the body has many localized stress responses, the two most common responses that influence nursing care are the reflex pain response and the inflammatory response. reflex pain response - is a response of the central nervous system to pain. It is rapid and automatic, serving as a protective mechanism to prevent injury. The reflex depends on an intact, functioning neurologic reflex arc and involves both sensory and motor neurons. For example, if you step into a bathtub of dangerously hot water, sensors in your skin detect the heat and immediately send a message to the spinal cord. A message is then sent to a motor nerve, which activates the muscles in your leg to pull back your foot. All of this happens before you consciously realize that the water is too hot to be safe. - very local one specific spot, hit arm, elbow, knee. You have sudden sharp localized pain. inflammatory response - is a local response to injury or infection. It serves to localize and prevent the spread of infection and promote wound healing. When you cut your finger, for example, you often develop the symptoms of the inflammatory response: pain, swelling, heat, redness, and changes in function. - response to injury or infection (also local, very specific) general adaptation syndrome (GAS) - means whole body - describes the body's general response to stress, a concept essential in all areas of nursing care. - The three stages in the GAS are alarm reaction, stage of resistance, and stage of exhaustion - Although the alarm stage is short term (minutes to hours), the length of the resistance and exhaustion stages varies greatly, depending on such variables as the severity and duration of the stressor, the person's previous health and coping mechanisms, and the immediacy and effectiveness of health care interventions. The GAS is a physiologic response to stress, but it is important to remember that the response results from either physical or emotional stressors. The stages occur with either physical or psychological damage to the person. Obvious examples are seen in patients with severe injury or an illness, but GAS is also a factor in mental illness, social isolation, and loss of (or lack of) human relationships. · Alarm reaction: initiated when a person perceives a stressor. The sympathetic nervous system initiates fight or flight. - This phase of the alarm reaction, called the shock phase, is characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. (If you recall the last time you almost had a car crash, you can easily identify these body reactions!) During the second phase of the alarm reaction, countershock, there is a reversal of body changes. · Stage of resistance: body attempts to adapt to the stressor - Vital signs, hormone levels, and energy production return to normal. If the stress can be managed or confined to a small area (LAS), the body regains homeostasis. If the stressor is prolonged or strong enough to overwhelm the body's ability to defend itself (e.g., severe injury and bleeding or a major illness such as cancer or a heart attack), the adaptive mechanisms become exhausted. · Stage of exhaustion: adaptive mechanisms can no longer provide defense - Exhaustion results when the adaptive mechanisms can no longer provide defense. This depletion of resources results in damage to the body in the form of wear and tear or systemic damage - Without defense against the stressor, the body may either rest and mobilize its defenses to return to normal or reach total exhaustion and die. - Physiologic Indicators of Prolonged Stress Backache or stiff neck Chest pain Constipation or diarrhea Decreased sex drive Dilated pupils Dry mouth Headache Increased urination Increased perspiration Increased pulse, blood pressure, and respirations Nausea Sleep disturbances Weight gain or loss PSYCHOLOGICAL HOMEOSTASIS (emotional) - each person needs to feel loved and a sense of belonging, to feel safe and secure, and to have self-esteem. When these needs are not met or a threat to need fulfillment occurs, homeostatic measures in the form of coping or defense mechanisms help return the person to emotional balance. Mind body interaction: - ex: student scheduled to take exam has rapid heartbeat and diarrhea - Since his wife was killed in a car crash, Tom Green has been the sole support of his 4-year-old son, who is developmentally disabled and hyperactive. Tom has been coming to the neighborhood health clinic with increasing frequency over the past 5 months, complaining of weight loss, headaches, and stomach pain. Anxiety - The most common human response to stress is anxiety. Anxiety is a vague, uneasy feeling of discomfort or dread, the source of which is often unknown or nonspecific. It is also a feeling of apprehension caused by anticipating a perceived danger. Anxiety is experienced at some time by all people and can involve a person's body, self-perceptions, and social relationships. Anxiety is a sign that alerts you to impending danger and enables you to take measures to manage a threat. - In contrast, fear is a feeling of dread in response to a known threat. Coping mechanisms: behaviors used to decrease stress and anxiety. (cry, laugh) Defense mechanisms: unconscious reactions to stressors. (angry, denial )

Identify the etiologies and defining characteristics for common fluid, electrolyte, and acid-base imbalances.

Fluid Volume Deficit (FVD) - hypovolemia - isotonic fluid loss. (caused commonly by vomiting, diarrhea, etc.) - is caused by a loss of both water and solutes in the same proportion from the ECF space. - Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. Fluid Volume Excess (FVE) - (caused commonly by kidney failure, heart failure, etc.) - Hypervolemia - excess fluid in the intravascular compartment - Edema - excess fluid in the interstitial space - Excessive retention of water and sodium in ECF in near-equal proportions - The excessive ECF may accumulate in either the intravascular compartments (hypervolemia) or interstitial spaces. - Accumulation of fluid in the interstitial space is known as edema. Edema can be observed around the eyes, fingers, ankles, and sacral space, and can also accumulate in or around body organs. Accumulation of fluid may result in a weight gain in excess of 5%. - Edema - typically starts in legs, swelling and pooling, pitting but edema can be anywhere and spreads to other parts of the body - Excess fluid in lungs : trouble breathing, coughing, abnormal breath sounds (crackles), - Weight gain from extra fluid Hypovolemia - bleeding, vomiting, diarrhea, not being able to take in fluids (swallowing issues) Hypervolemia - too much sodium in diet, renal issues, congestive heart failure

KEY TERMS

Hypoxia - inadequate amount of oxygen available to the cells - Low oxygen saturation of the body, not enough oxygen in the blood Dyspnea - difficulty breathing Ventilation - movement of air in and out of the lungs Perfusion - Circulation of blood within an organ or tissue in adequate amounts to meet current needs of the cells. Hypoventilation - decreased rate or depth of air movement into the lungs Hyperventilation - increased rate and depth of ventilation, above the body's normal metabolic requirements - hyperventilation can lead to a lowered level of arterial carbon dioxide.

Describe the functions, regulation, sources, and losses of the main electrolytes of the body.

INTAKE - mainly through what we eat and drink if we are not taking in enough, then the balance is broken - ingested liquids, food, and as a byproduct of metabolism. The ingestion of liquids provides the largest amount of water normally taken into the body. Fluid intake is regulated primarily by the thirst mechanism OUTPUT - urination, sweating, stool, wounds - Fluid is lost from the body through sensible and insensible losses. -- Sensible losses can be measured and include fluid lost during urination, defecation, and wounds. - kidneys = urination, intestinal tract = feces, skin = perspiration -- Insensible losses cannot be measured or seen and include fluid lost from evaporation through the skin and as water vapor from the lungs during respiration.

Describe how thirst and the organs of homeostasis (kidneys, heart and blood vessels, lungs, adrenal glands, pituitary gland, parathyroid glands) function to maintain fluid homeostasis.

Kidneys - Retention and excretion of body fluids Heart and blood vessels - Circulation Lungs- control levels of CO2 Adrenal glands- regulate blood volume and sodium and potassium balance by secreting aldosterone Pituitary gland- releases antidiuretic hormone resulting in water conservation or water loss Parathyroid gland - parathyroid hormone regulates calcium and phosphate IN DEPTH KIDNEYS: - Regulate extracellular fluid (ECF) volume and osmolality by selective retention and excretion of body fluids - Regulate electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances - Regulate pH of ECF by excretion or retention of hydrogen ions - Excrete metabolic wastes (primarily acids) and toxic substances - Normally filter 180 L of plasma daily in the adult, while excreting only 1.5 L of urine HEART AND BLOOD VESSELS: - Circulate nutrients and water throughout the body - Circulate blood through the kidneys under sufficient pressure for urine to form (pumping action of the heart) - React to hypovolemia by stimulating fluid retention (stretch receptors in the atria and blood vessels) LUNGS: - Remove approximately 300 mL of water daily through exhalation (insensible water loss) in the normal adult - Eliminate about 13,000 mEq of hydrogen ions (H+) daily, as opposed to only 40 to 80 mEq excreted daily by the kidneys - Act promptly to correct metabolic acid-base disturbances; regulate H+ concentration (pH) by controlling the level of carbon dioxide (CO2) in the extracellular fluid ADRENAL GLANDS: - Regulate blood volume and sodium and potassium balance by secreting aldosterone, a mineral corticoid secreted by the adrenal cortex, causing sodium retention (and thus water retention) and potassium loss. - Decreased secretion of aldosterone causes sodium and water loss and potassium retention. - Cortisol, another adrenocortical hormone, has only a fraction of the potency of aldosterone. However, secretion of cortisol in large quantities can produce sodium and water retention and potassium deficit. PITUITARY GLAND: - Stores and releases the antidiuretic hormone (ADH) (manufactured in the hypothalamus), which acts to allow the body to retain water. It acts chiefly to regulate sodium and water intake and excretion. - When osmotic pressure of the ECF is greater than that of the cells (as in hypernatremia—excess sodium—or hyperglycemia), ADH secretion is increased, causing renal retention of water. - When osmotic pressure of the ECF is less than that of the cells (as in hyponatremia), ADH secretion is decreased, causing renal excretion of water. - When blood volume is decreased, an increased secretion of ADH results in water conservation. When blood volume is increased, a decreased secretion of ADH results in water loss. PARATHYROID GLAND: - Regulate calcium (Ca2+) and phosphate (HPO42−) balance by means of parathyroid hormone (PTH); PTH influences bone reabsorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules. - Increased secretion of PTH causes elevated serum calcium concentration and lowered serum phosphate concentration. - Decreased secretion of PTH causes lowered serum calcium concentration and elevated serum phosphate concentration.

Identify factors that affect respiratory and cardiovascular function.

Level of health - chronic illnesses- muscle wasting, poor muscle tone - renal or cardiac disorders- compromised respiratory function - anemia- inadequate supply of oxygen to the tissues - MI- lack of blood supply to the heart muscle - physical changes like scoliosis can cause air trapping - obesity, lack of exercise, decreased stimulation in alveoli Developmental considerations Medication considerations- drugs that affect CNS need to be monitored for respiratory complications, e.g. opioids - Be alert for the possibility of respiratory depression or arrest when administering any narcotic or sedative. Lifestyle considerations - activity levels, sedentary do not promote expansion of alveoli and development of pulmonary exercise patterns, exercise- better response to stressors - cigarette smoking Environmental considerations - air pollution correlated with cancer and lung disease - Occupational exposure to asbestos, silica, or coal dust, as well as environmental pollution, can lead to chronic pulmonary disease. Chronic exposure to radon, radiation, asbestos, and arsenic can lead to lung cancer. Psychological health considerations - hyperventilation in response to stress, generalized anxiety- bronchial asthma

Explain the concepts of loss and grieving, including types of loss and grief reactions.

Loss, actual loss, perceived loss, anticipatory loss, grief, mourning, bereavement, palliative care, hospice care Loss - occurs when a valued person, object, or situation is changed or becomes inaccessible such that its value is diminished or removed. Actual loss - can be recognized by others as well as by the person sustaining the loss—for example, loss of a limb, a child, a valued object such as money, and a job. Perceived loss - such as loss of youth, financial independence, or a valued environment, is experienced by the person but is intangible to others. Directly related to actual and perceived loss are physical and psychological loss. A person who loses an arm in an automobile crash suffers from both the physical loss of the arm and the psychological loss that may be caused by an altered self-image and the inability to return to his or her occupation or other activities. These losses are simultaneously physical, psychological, and actual. A person who is scarred but does not lose a limb may suffer a perceived and psychological loss of self-image. Anticipatory loss - occurs when a person displays loss and grief behaviors for a loss that has yet to take place - is often seen in the families of patients with serious and life-threatening illnesses and may lessen the effect of the actual loss of the family member. Grief - is an internal emotional reaction to loss. It occurs with loss caused by separation or by death. - For example, many people who divorce experience grief. Loss of a body part, job, house, or pet may also cause grief. - Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating yourself from social contact), and spiritual (questioning the reason for your loss, the purpose of pain and suffering, the purpose of life and the meaning of death). Mourning - is the actions and expressions of that grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life) that make up the outward expressions of grief. Bereavement - is a state of grieving due to loss of a loved one. - showing grief/mourning over a person Palliative care - involves taking care of the whole person—body, mind, and spirit, heart and soul. It views dying as something natural and personal. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. - can be for anyone, for example someone with chronic illness, housing them and dealing w them whether it is death or chronic illness. Has a holistic approach. Management. Hospice care - is care provided for people with limited life expectancy, often in the home. When considering whether a patient is a candidate for hospice care, ask yourself, "Would I be surprised if this person died within the next 6 months?" - people closer to death (like 6 months of life or so) severely ill. More about comfort care. -AIDS, dementia, cancer, CHF Grief Reactions: the stages of grief reactions overlap and vary among people. One person may skip a reaction stage, etc. - More important than the actual stages of any given grief reaction is the idea that grief is a process that varies from person to person. Dysfunctional grief: is abnormal, may have trouble expressing feelings of loss or may deny them - Someone is stuck in a stage, like denial. Not dealing w the stages and is grieving for years. DON'T NEED TO KNOW : Engel's six stages are (1) shock and disbelief, (2) developing awareness, (3) restitution, (4) resolving the loss, (5) idealization, and (6) outcome. Kübler-Ross five stages: (1) denial and isolation, (2) anger, (3) bargaining, (4) depression, and (5) acceptance

Describe nursing strategies to promote adequate oxygenation and identify their rationale.

Provide supplemental oxygen, oxygen safety p. 1509 box 39-1 Healthy lifestyle - weight, exercise, stop smoking, limit alcohol, nutrition Vaccinations - flu and pneumococcal Environment teaching - pollution Reducing Anxiety Positioning - high fowlers Adequate fluid intake to keep secretions thin Humidified Air Proper breathing - deep breathing, incentive spirometry Teaching about a pollution-free environment - involve a job change, use of protective equipment, requesting enforcement of laws by government facilities, or subcontracting jobs. - In order to minimize triggers in the home, dusting and vacuuming the office and home must be done at least twice per week. - exposure to industrial or occupational hazards (e.g., paint, varnish, gaseous fumes, asbestos) must also be restricted. Promoting optimal function: - Encourage patients to eat a healthy diet - maintain healthy weight - Regular exercise - monitor their cholesterol, triglyceride, lipoprotein (HDL) and low-density lipoprotein levels (LDL), as well as their blood pressure. - Encourage patients to limit alcohol intake and stop smoking Promoting comfort - A proper position for breathing is a position that allows free movement of the diaphragm and expansion of the chest wall. - High fowlers - maintain fluid intake - humidifiers Promoting proper breathing - deep breathing - use incentive spirometry: An incentive spirometer assists the patient to breathe slowly and deeply and to sustain maximal inspiration. The gauge on the spirometer allows the patient to measure one's own progress, providing immediate positive reinforcement. It encourages the patient to maximize lung inflation and prevent or reduce atelectasis. - pursed lip breathing: exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration. Prolonged expiration is thought to result in decreased airway narrowing during expiration and prevent the collapse of small airways. - DIAPHRAGMATIC BREATHING: The patient breathes in slowly through the nose, letting the abdomen protrude as far as it will go, then breathes out through pursed lips while contracting the abdominal muscles, with one hand pressing inward and upward on the abdomen. Managing chest tubes - A chest tube is indicated when negative pressure in the pleural space is disrupted, as from thoracic surgery or unanticipated trauma. Patients with fluid (pleural effusion), blood (hemothorax), or air (pneumothorax) in the pleural space require a chest tube to drain these substances and allow the compressed lung to re-expand - Nursing responsibilities include assisting with insertion and removal of a chest tube. Once the tube is in place, monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system. - Nursing responsibilities related to chest tube removal also include providing emotional support for the patient, as well as monitoring the patient's status after removal. Monitor the patient's respiratory status, vital signs, pain, and site dressing. Promoting and controlling coughing Suctioning the airway - Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Meeting oxygenation needs with medications - Many of the drugs used to dilate bronchial airways interact with caffeine. Encourage patients to avoid caffeine, which may potentiate the side effects of bronchodilators. - Patients need repeated instruction on how to use inhalers and nebulizers effectively and safely. Overuse may result in serious side effects and eventual ineffectiveness of the medication. Nebulizers require cleaning after use, thus patients must understand how to do this correctly. - Oxygen therapy, which provides supplemental oxygen, can increase the amount of oxygen transported in the blood. Oxygen is considered a medication and must be ordered by a health care provider.

Electrolyte values

Sodium 135 - 145 mEq/L Potassium 3.5 - 5 mEq/L Calcium 8.6 - 10.2 mg/dL Magnesium 1.3 - 2.3 mEq/L Chloride 97 - 107 mEq/L Bicarbonate 25 - 29 mEq/L Phosphate 2.5 - 4.5 mg/dL Sodium (Na+): chief electrolyte of ECF; normal serum concentration of sodium: 135-145 mEq/L FUNCTIONS: - Regulates extracellular fluid volume; Na+ loss or gain accompanied by a loss or gain of water - Affects serum osmolality - Role in muscle contraction and transmission of nerve impulses - Regulation of acid-base balance as sodium bicarbonate SOURCES AND LOSSES: - Normally enters the body through the gastrointestinal tract from dietary sources, such as salt added to processed foods, sodium preservatives added to processed foods - Lost from gastrointestinal tract, kidneys, and skin REGULATION: - Transported out of the cell by the sodium-potassium pump - Regulated by renin-angiotensin-aldosterone system - Elimination and reabsorption regulated by the kidneys - Sodium concentrations affected by salt and water intake Potassium (K+): major cation of ICF; normal serum concentration of potassium: 3.5-5.0 mEq/L FUNCTIONS: - Controls intracellular osmolality - Regulator of cellular enzyme activity - Role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal, and lung tissue; Regulation of acid-base balance by cellular exchange with H+ SOURCES AND LOSSES: - Adequate quantities via a well-balanced diet - Leading food sources: fruits and vegetables, dried peas and beans, whole grains, milk, meats - Lost via kidneys, stool, sweat, emesis REGULATION: - Regulated by aldosterone - Eliminated by the kidneys (no effective method of conserving potassium) - Additional regulation via transcellular shift between the ICF and ECF compartments Calcium (Ca2+): most abundant electrolyte in the body; normal total serum calcium level: 8.6-10.2 mg/dL; normal ionized serum calcium level: 4.5-5.1 mg/dL FUNCTIONS: - Role in blood coagulation and in transmission of nerve impulses - Helps regulate muscle contraction and relaxation - Major component of bones and teeth SOURCES AND LOSSES: - Absorbed from foods in the presence of normal gastric acidity and vitamin D - Lost via feces and urine - Sources include milk and milk products; dried beans; green, leafy vegetables; small fish with bones; and dried peas and beans - Primarily excreted by gastrointestinal tract; lesser extent by kidneys REGULATION: - Regulated by parathyroid hormone and calcitonin - High serum phosphate results in decreased serum calcium; low serum phosphate leads to increased serum calcium Magnesium (Mg2+): second most abundant ICF cation after potassium; normal serum concentration of magnesium: 1.3-2.3 mEq/L FUNCTION: - Metabolism of carbohydrates and proteins - Role in neuromuscular function - Acts on cardiovascular system, producing vasodilation SOURCES AND LOSSES: - Enters the body via gastrointestinal tract - Sources include green, leafy vegetables; nuts; seafood; whole grains; dried peas and beans; cocoa - Lost via urine with use of loop diuretics - Eliminated by kidneys REGULATION: - Regulated by parathyroid hormone Chloride (Cl−): major ECF anion; normal serum level of chloride: 97-107 mEq/L FUNCTION: - Major component of interstitial and lymph fluid; gastric and pancreatic juices, sweat, bile, and saliva - Acts with sodium to maintain the osmotic pressure - Combines with hydrogen ions to produce hydrochloric acid SOURCES AND LOSSES: - Enters body via gastrointestinal tract - Almost all chloride in diet comes from salt - Found in foods high in sodium, processed foods - Normally paired with sodium; excreted and conserved with sodium by the kidneys REGULATION: - Regulated by aldosterone - Low potassium level leads to low chloride level Bicarbonate (HCO3−): an anion that is the major chemical base buffer within the body; found in both ECF and ICF; normal serum bicarbonate level: 25-29 mEq/L FUNCTION: - Regulates acid-base balance SOURCES AND LOSSES: - Losses possible via diarrhea, diuretics, and early renal insufficiency - Excess possible via over-ingestion of acid neutralizers, such as sodium bicarbonate REGULATION: - Bicarbonate levels regulated primarily by the kidneys - Bicarbonate readily available as a result of carbon dioxide formation during metabolism Phosphate (PO4−): major ICF anion; a buffer anion in both ICF and ECF; normal serum phosphate level: 2.5-4.5 mg/dL FUNCTIONS: - Role in acid-base balance as a hydrogen buffer - Promotes energy storage; carbohydrate, protein, and fat metabolism - Bone and teeth formation - Role in muscle and red blood cell function SOURCES AND LOSSES: - Enters body via gastrointestinal tract - Sources include all animal products (meat, poultry, eggs, milk, bread, ready-to-eat cereal) - Absorption is diminished by concurrent ingestion of calcium, magnesium, and aluminum - Eliminated by kidneys REGULATION: - Regulation by parathyroid hormone and by activated vitamin D - Phosphate and calcium are inversely proportional; an increase in one results in a decrease in the other

Describe the signs of impending death.

The clinical signs of impending or approaching death include: (everything decreases) -Difficulty talking or swallowing -Nausea, flatus, abdominal distention -Urinary or bowel incontinence or constipation -Loss of movement, sensation, and reflexes -Decreasing body temperature with cold or clammy skin -Weak, slow, or irregular pulse -Decreasing blood pressure -Noisy, irregular, or Cheyne-Stokes respirations -Restlessness or agitation -Cooling, mottling, and cyanosis of the extremities and dependent areas As death nears, the patient may have a decreased level of consciousness or agitated delirium. Although decreased consciousness and agitation are both normal at the end of life, they are very distressing to the patient's family. It is important for nurses to prepare family members when death is imminent and to determine if they are more comfortable being alone with a dying loved one or supported by a nurse or other member of the professional caregiving team.

Ch. 40 - Describe the location and functions of body fluids, including the factors that affect variations in fluid compartments

Water in the body functions: · Transport nutrients, hormones, enzymes, etc. · Facilitate metabolism and cell functioning · Maintain normal body temperature · Promote elimination · Act as a tissue lubricant Body fluid compartments - Intracellular (within the cells) vs. extracellular (outside the cells) - Extracellular includes Intravascular (liquid component of blood) and interstitial (fluid that surrounds tissue cells) compartments Body fluid is located in two fluid compartments—the intracellular fluid or extracellular fluid, based on its location in the body. - Intracellular fluid (ICF) is the fluid within cells, constituting about 70% of the total body water or 40% of the adult's body weight. - Extracellular fluid (ECF) is all the fluid outside the cells, accounting for about 30% of the total body water or 20% of the adult's body weight. ECF includes two major areas, the intravascular and interstitial compartments. A third, usually minor, compartment is the transcellular fluid. - Intravascular fluid, or plasma, is the liquid component of the blood (i.e., fluid found within the vascular system). - Interstitial fluid is the fluid that surrounds tissue cells and includes lymph - Transcellular fluids include cerebrospinal, pericardial, synovial, intraocular, and pleural fluids, as well as sweat and digestive secretions. Variations · Age - infants vs older adults - Infants have considerably more total body fluid and ECF than adults. Because ECF is more easily lost from the body than ICF, infants are at increased risk for fluid volume deficits. - older adults : the decreasing percentage of body fluid in older people is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults. · Body fat - Fat cells contain little water, whereas lean tissue is rich in water. - Thus, the more obese a person is, the smaller the person's percentage of total body water is when compared with body weight. · Biological sex - Because women tend to have proportionally more body fat than men do, they also have less body fluid than men. - Healthy person: total body water is 50% to 60% of body weight - An infant has considerably more body fluid and ECF than an adult; more prone to fluid volume deficits - Gender and amount of fat cells affect body water; women and obese people have less body water

Integrate knowledge of healthy lifestyle, support systems, stress management techniques, and crisis intervention into hospital-and community-based care.

· Healthy lifestyle - exercise, rest/sleep, nutrition - Regular exercise helps maintain physical and emotional health. The benefits of exercise include an improved musculoskeletal system, more effective cardiovascular function, weight control, and relaxation. Exercise improves a person's general sense of well-being, relieves tension, and enables coping with day-to-day stressors. - Rest and sleep help the body maintain homeostasis and restore energy levels. Adequate rest can provide insulation against stress, but stress may interfere with a person's ability to sleep. - Nutrition plays an active role in maintaining the body's homeostatic mechanisms and in increasing resistance to stress. · Support systems - family, support groups · Stress management techniques - CAM therapies (relaxation, meditation, etc.) - Relaxation promotes a body reaction opposite to that of the fight-or-flight response: respiratory, pulse, and metabolic rates, as well as blood pressure and energy use, can all be decreased using relaxation methods. - Meditation has four components: quiet surroundings, a passive attitude, a comfortable position, and a word or mental image on which to focus. A person practicing meditation sits comfortably with closed eyes, relaxes the major muscle groups, and repeats the selected word silently with each exhalation. - guided imagery - biofeedback · Crisis intervention - 5 step problem solving technique 1. Identify the problem (diagnosing) 2. List alternatives (or interventions) 3. Choose from among alternatives 4. Implement the plan 5. Evaluate the outcome