NUR 316 Exam #3

Normal body temperature (Normothermia)

- 36.5 -37.2 degrees C - 96.8 to 99.5 degrees F

risk factors for pain

- Age - Communication barriers - Cognitive impairment - Mental Health condition - Injuries - Cultures - Coping techniques - Support - Previous experiences - Anxiety

Interventions for fevers

- Antipyretics are medications that reduce fever. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetaminophen, salicylates, indomethacin, and ketorolac reduce fever by increasing heat loss. Corticosteroids reduce heat production by interfering with the immune system and mask signs of infection. They are not used to treating a fever. However, they can suppress fever in response to pyrogen. - Nonpharmacological therapy for fever uses methods that increase heat loss through evaporation, conduction, convection, or radiation.

Primary Prevention for thermoregulation issues

- Avoid exposure to temperature extremes - Maintain the optimal ambient temperature in the home - Dress appropriately for the temperature - Engage in physical activity appropriate to temperature conditions

Fever (pyrexia)

- Elevation in body temperature due to a change in the hypothetical set point - body is alerting your to infection or foreign invader

Hyperpyrexia

- Extremely high body temperature above 41.5 degrees C - increases risk of seizures

basic temperature information

- Fever is usually not harmful if it stays below 39° C (102.2° F) in adults or below 40° C (104° F) in children. - Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period. The temperature is usually lowest between 1:00 and 4:00 a.m. During the day, body temperature rises steadily to a maximum temperature value at about 4:00 p.m. and then declines to early-morning levels. - When a fever breaks, the term is "afebrile." - Fever is an important defense mechanism. Mild temperature elevations as high as 39° C (102.2° F) enhance the immune system of the body. - Physical and emotional stress increase body temperature through hormonal and neutral stimulation. - Exercise stimulates muscle activity and requires an increased blood supply and increased carbohydrate and fat breakdown. Exercise will increase heat production and body temperature.

Safety Guidelines

- Follow proper aseptic technique. - Routinely assess for risks of pressure injuries. - Inspect skin daily. - Use approaches to minimize friction and shear. - Modify the frequency of wound assessment based on wound condition. - Chronic diseases, especially vascular disease and diabetes, increase a patient's risk for pressure injury development and impede healing of wounds.

Complications of wound healing

- Hemorrhage - release of blood from a blood vessel, which brings oxygen and nutrients to the wound. - Infection - bacteria can enter wounds that prevent immune cells from killing bacteria and these delays wound healing. - Dehiscence - an opening in the wound can impede wound healing because it is open and allows bacteria to get in and infect the wound. - Evisceration - if the wound separates significantly, your internal organs and tissue could push out of the incision.

PCA (patient controlled analgesia)

- IV infusion device that patient controls - can deliver a continuous baseline amount & patient controlled bolus as needed - opioids - lockout limit - monitor PCA pump every 4 hours and VS every hour - have naloxone (Narcan) prepared

Risk factors for pressure ulcer development

- Impaired sensory perception - Impaired mobility - Alteration in LOC - Shear - Friction - Moisture

differences between nursing care for acute and chronic wounds

- Nursing care for an acute wound includes assessing the wound, cleaning it, and providing interventions to continue to promote healing. - Nursing care for a chronic wound include disinfecting the wound and decontaminating it, remove any dead tissue, apply appropriate wound dressings, manage the wound based on the stage, keep the wound moist, apply topical antibiotics and antiseptics as directed.

Factors influencing pressure injury formation and wound healing

- Nutrition - Tissue perfusion - Infection - Age - Psychosocial impact of wounds

OLDCART

- Onset - Location - Duration - Characteristics - Aggravating factors - Relieving factors - Treatment

Nursing guidelines for administering analgesics safely.

- Pain is usually initially assessed and a pain management plan is made. Then, pain is reassessed and documented on a regular basis to evaluate the effectiveness of the treatments. - A fast-onset, short-acting formulation of a first-line analgesic, such as morphine, oxycodone, hydromorphone, or fentanyl, is used to manage breakthrough pain. Analgesic doses or the frequency of their administration is adjusted as needed to minimize the occurrence of breakthrough pain.

wound repair

- Partial-thickness wound repair: inflammatory response, epithelial proliferation and migration, and reestablishment of the epidermal layers - Full-thickness wound repair: hemostasis, inflammatory, proliferative, and maturation

the normal process of wound healing

- Partial-thickness wounds repair: inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. - Full-thickness wounds repair: hemostasis, inflammatory, proliferative, and maturation. - Primary intention occurs when wound margins are well approximated, as in a sutured surgical incision or a simple laceration; it takes place more rapidly than the other types of healing. - Secondary intention occurs when wounds such as ulcerations have distant edges and granulation tissue gradually fills the gap to close the wound. - Protein, vitamin A and vitamin C are particularly critical for collagen synthesis in wound healing. In the absence of adequate nutrition, wound healing is delayed, and infection is more likely.

chronic pain

- Persistent or recurring pain that is often difficult to treat and effects a patients quality of life - longer than 6 months - ex arthritis, diabetes, IBS, fibromyalgia, back pain

various factors that influence pain

- Physiological (Age, fatigue, genes, neurological function) - Social (Previous experience, family and social network, spiritual factors) - Psychological (Attention, anxiety and fear, coping style) - Culture (Meaning of pain, ethnicity)

Individual Risk Factors for Wounds

- Poor peripheral perfusion - Malnutrition or obesity - Dehydration or edema - Impaired mobility - Immunosuppression - Radiation, temperature extremes, chemical or mechanical trauma, medical treatments - Friction, shearing, moisture, pressure

Osteoarthritis

- Progressive inflammatory degenerative disease of diarthrodial joints - cartilage swells, joint space narrows, joint cartilage deteriorates, synovial fluid leaks into bone defects causing cysts - joint pain or tenderness on palpation, limited joint movement, swelling or hard nodules on joints - treatment: weight loss, heat/cold, PT/OT, Tylenol or NSAIDs for pain, intra- articular corticosteroid, surgery - Alendronate (Fosamax): can treat or prevent osteoarthritis

Physiological responses to pain

- Sympathetic Nervous System (mild to moderate pain) - increased RR (dilates bronchioles ), increased HR and increased BP (vasoconstriction), pallor or pale, increased glucose, diaphoresis, dilated pupils, slows GI motility leads to constipation, increased muscle tension - Parasympathetic Nervous System (severe pain) - rapid and irregular RR, decreased HR and BP, pallor, nausea and vomiting

nociceptive pain

- The cells of free nerve endings in the skin and peripheral organs that are somatosensory receptors for the sensation of pain are known as nociceptors. The somatosensory system is a network of neuro muscles that is concerned with the perception of pain. - normal process that results in noxious stimuli being perceived as painful - arises from tissues damaged by physical or chemical agents such as trauma, surgery, or chemical burns - somatic - in the muscles, bones, or soft tissues - visceral - internal organs and blood vessels - cutaneous - skin

Symptoms of Necrotic Wounds

- There are two main types of necrotic tissue present in wounds: eschar and slough. - Eschar presents as dry, thick, leathery tissue that is often tan, brown or black. - Slough is characterized as being yellow, tan, green or brown in color and may be moist, loose and stringy in appearance.

Treatments & Interventions for Necrotic Wounds

- Treatment of necrosis typically involves two distinct steps. - The underlying cause of the necrosis in wounds must be treated before the dead tissue itself can be dealt with. This can mean anything from administering antibiotics or antivenom to relieving pressure on the wound area to restore perfusion. - After the cause has been addressed, the necrotic tissue will need to be removed. Depending on the extent of necrosis, this can mean surgical, mechanical, or enzymatic debridement of the wound, or complete amputation of the affected area.

Modulation

- a release of neurotransmitters that are inhibiting or blocking pain

Hyperthermia

- abnormally high body temperature - Body temperature above 37.6 degrees C - most commonly caused by extreme increase in environmental temperature - SE: dehydration, hypotension, tachycardia, decreased CO2, reduced perfusion, cardiovascular collapse, cerebral edema, renal necrosis, CNS degeneration

Hypothermia

- abnormally low body temperature - Body temperature below 36.2 degrees C - caused by extremely low environmental temperatures - risk factors: diabetes, hypothyroidism - SE: shivering, loss of memory, depression, poor judgement, bradycardia, bradypnea, hypotension, cyanosis, and frostbite

Behavioral responses to pain

- acute- teeth clenching, tight jaw, facial grimacing, guarding, moaning - chronic - lack of appetite, lack of sleep, confusion, irritability, fatigue, lack of motivation, depression

Factors effecting body temperature

- age - exercise - hormone level - circadian rhythm - stress - environment - temperature alterations

Malignant Hyperthermia

- an inherited muscle disorder, a hypermetabolic disorder of skeletal muscle triggered by the induction of general anesthesia that leads to severe hyperthermia. - Signs/symptoms: tachycardia, hypertension, acid-base and electrolyte abnormalities, muscle rigidity, and hyperthermia. - acute life threatening complication of certain drugs for general anesthesia - causes increased calcium in skeletal muscle cells and increase in metabolism - increased CA and K leads to acidosis, dysrhythmias, high temp - increase HR, RR, decrease BP, muscle rigidity, mottling, cyanosis - Treatment: IV Dantrolene (skeletal muscle relaxant)

pain

- an unpleasant sensory and emotional experience associated with actual or potential tissue damage, both physical and psychological, and is exactly what the patient says it is. - the patient report is the most reliable indicator of pain - subjective - often under-recognized, misunderstood, and inadequately treated - no two people experience pain in the same way - The cells of free nerve endings in the skin and peripheral organs that are somatosensory receptors for the sensation of pain are known as nociceptors. The somatosensory system is a network of neuro muscles that is concerned with the perception of pain.

With decreased temerature

- blood vessels constrict, sweat glands become less active, skeletal muscle contract causing shivering (warms them up)

with increase temperature

- blood vessels dilate, flushed skin appearance, and sweat glands become more active

Fracture

- break in the bone - treatment- open fracture: surgery, antibiotics for infection prevention, check pulses distal to break - Immobilize: splint above and below the fracture; traction - closed reduction: manual manipulation without skin incision to restore displaced bone segments to their normal positions (for less-severe fracture), after which cast, splint, or other type of immobilization device is applied - external fixation device for severe fractures with significant soft-tissue injury to immobilize the fractures and allow for access to the wound for dressing changes and monitoring for infection - open reduction and internal fixation: surgical reduction and fracture immobilization using rods, plates, or screws; used when closed reduction is impossible

causes of necrosis

- can be caused by a number of external sources, including injury, infection, cancer, infarction, poisons, and inflammation. Black necrotic tissue is formed when healthy tissue dies and becomes dehydrated, typically as a result of local ischemia. Common causes of ischemia are diabetes or other metabolic disorders, or unrelieved local pressure that compresses soft tissue between a surface and underlying bony prominences (leading to the formation of pressure ulcers).

rheumatoid arthritis

- chronic, systemic, symmetrical autoimmune inflammatory disease - primarily attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels - remissions and exacerbations - joint pain and swelling; most common, but can have pulmonary and CV - treatment: lifestyle changes, heat/cold, splinting, exercise, relaxation, and stress management, Disease Modifying Anti Rheumatoid Drugs (ex: methotrexate)

neuropathic pain

- happens if your nervous system is damaged or not working correctly - often described as a shooting or burning pain - ex: diabetic neuropathy

Gout

- inflammatory arthritis caused by monosodium urate monohydrate crystal deposits - Elevated uric acid level - uric acid crystalizes in blood of body fluids, and the precipitate accumulates in connective tissue - primary - high uric acid levels - secondary - metabolic syndrome - red, swollen, painful joints (feet) often pain in great toe - treatment: identify provoking factors, cold, diet low in purine, increase fluids, weight loss, colchicine, allopurinol, NSAIDs for pain

non-pharmalogical pain management

- massage, acupuncture, heat and cold therapy, splints, music therapy, exercise, yoga, guided imagery, meditation, repositioning, TENS unit

pharmacological pain management

- non opioid - acetaminophen or NSAIDS like ibuprofen, aspirin, naproxen, toradol - opioid - morphine, oxycodone, fentanyl, hydrocodone, codeine, methadone, dilaudid, - adjuvant drugs - antidepressants, anticonvulsants, corticosteroids, neuroleptics

Nocicceptors

- pain receptors

cancer pain

- pain resulting from any of a variety of causes related to cancer and/or the metastasis of cancer

How do we lose heat?

- radiation - heat from the surface of one object transferring to another without contact. - conduction - contact with another person causing warmth - convection - heat by air movement - evaporation - transfer of heat when liquid is changed to a gas. diaphoresis or sweating

interventions for hyperthermia

- remove excess clothing and blankets - provide external cool packs - cooling blanket - hydrate with cool fluids (oral or IV) - lavage with cool fluids - administer antipyretic drug therapy

interventions for hypothermia

- remove person from the cold - external warming measures - internal warming measures Safety tip -> core rewarming must be done slowly to minimize the risk for dysrhythmias. Cardiac monitoring is required when a patient is recovering from severe hypothermia.

acute pain

- short-term, self-limiting, often predictable trajectory; stops after injury heals - less than 6 months - ex: cut, bruise, pulled muscle, broken bone

Sprains vs Strains

- sprain - complete of incomplete tear in supporting ligaments around a joint; pain on passive movement, swelling, bruising - strain - acute or chronic injury to a muscle or tendinous attachment; pain on isometric contraction, cramping, weakness, spasms - treatment: RICE, elastic bandage wrap, air cast, splint, brace, crutches, Tylenol or NSAIDs

Transmission

- stimuli that releases neurotransmitters that are notifying you that your are experiencing pain

Transduction

- stimuli that results in pain ex: touching a hot surface

Necrosis

- the death of cells in living tissue caused by external factors such as infection, trauma, or toxins. As opposed to apoptosis, which is naturally occurring and often beneficial planned cell death, necrosis is almost always detrimental to the health of the patient and can be fatal. Typically, cells that die as a result of necrosis do not signal nearby phagocytes to ingest said dead cells, which leads to a build up of dead tissue and cell debris. - can delay wound healing, and it is often necessary for the devitalized tissue to be removed before any progress towards healing can be made. For this reason, it is often necessary to remove necrotic tissue surgically, a process known as debridement. - When substantial areas of tissue become necrotic due to lack of blood supply, this is known as gangrene.

traction

- treatment that exerts a pulling force on part of the body, by applying force directly to the bone - Used to reduce fractures, treat dislocations, correct or prevent deformities, or improve of correct contractures - maintain proper body alignment - meticulous skin care, pin-site care - immobile- DVT prevention, C&DB, ROM, nutritious diet for healing, stool softeners/laxatives - Watch for infection - Neurovascular status- pain, pallor, pulses, paresthesia

Preception

- your awareness of pain that's influenced by experiences

antipyretic drugs

Aspirin, Acetaminophen, Ibuprofen, Motrin, Advil

Identify barriers to effective pain management

Language/communication, age, culture, cognitive impairment, substance abuse

Evaluate a patient's response to pain interventions

Reassessing pain and asking all the described questions to fully understand their pain is a good way to evaluate a patient's response to pain interventions.

Classification of pressure injuries

Stage 1: Non-blanchable erythema of intact skin Stage 2: Partial-thickness skin loss with exposed dermis Stage 3: Full-thickness skin loss Stage 4: Pressure Injury: Full-thickness skin and tissue loss Unstageable

Thermoregulagtion

The process of maintaining the core body temperature at a nearly constant value. Temperature is controlled by the hypothalamus through neutral and hormonal control.

Provide appropriate nursing and collaborative interventions to optimize thermoregulation.

When a client has an elevated body temperature, the underlying cause of it should be first identified. When a client has a temperature greater than 37 degrees C, we should first remove excess clothing and blankets. If the symptoms of hyperthermia continue after 1-hour, further intervention is required. Signs and symptoms that persist beyond 1 hour require further intervention. Hydration, nutritional support, and other palliative measures to reduce core temperature should be implemented. Cool packs may be placed in the axillary and groin areas; a cooling blanket or lukewarm bath may also facilitate temperature reduction. Care should be taken not to induce shivering. More aggressive cooling efforts include gastric or colonic lavage with cool fluids.

A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? a. Core rewarming with warm fluids b. Ambulation to increase metabolism c. Frequent oral temperature assessment d Gastric tube feedings to increase fluids

a

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: a. you compare assessed pain w/baseline pain. b. body language is incongruent with reports of pain relief. c. family members report that pain has subsided. d. vital signs have returned to baseline.

a

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? a. Ice bag b. Binder c. Absorptive dressing d. Elastic bandage

a

Hyperthermia or Hypothermia?- Decreased BP, increased HR, increased RR, dry flushed skin, dry mucous membranes.. a. Hyperthermia b. Malignant Hyperthermia c. Hypothermia

a

The nursing assistant asks you the difference between a wound that heals by primary intention or secondary intention. You will reply that a wound heals by primary intention when the skin edges: a. are approximated. b. migrate across the incision. c. appear slightly pink. d. slightly overlap each other.

a

Which patient is at the highest risk for tachycardia? a. A patient with a temperature of 39.4 b. A healthy football player during warm up exercises c. A patient admitted with hypothermia d. A 90 year old male taking Metoprolol

a

Which of the following are measures to reduce tissue damage from shear? Select all that apply a. Raise head of bed 30 degrees when patient positioned supine b. Raise head of bed 60 degrees when patient positioned supine c. Use a transfer device, e.g. transfer board d. Have head of bed flat when re positioning patients e. Have head of bed elevated when transferring patient

a, c, d

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? Select all that apply a. Using an incontinence cleaner b. Frequent position changes. c. Using a large absorbent diaper, changing when saturated d. Keeping the buttocks exposed to air at all times e. Applying a moisture barrier ointment f. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

a, e

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? a. Behaviors b. Patient's self-report c. Vital sign changes d. Surrogate (wife) report

b

Hyperthermia or Hypothermia? - Depression, loss of memory, unresponsiveness to painful stimuli, and poor judgment a. Malignant Hyperthermia b. Hypothermia c. Hyperthermia

b

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates a. rapid pulse rate b. slow capillary refill c. increased respirations d. red, sweaty skin.

b

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? a. Chronic pain is psychological in nature. b. Patients are the best judges of their pain. c. Regular use of narcotic analgesics leads to drug addiction. d. Amount of pain is reflective of actual tissue damage.

b

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? a. Sensitive skin that requires special bed linen b. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode c. A stage III pressure ulcer needing the appropriate dressing d. A local skin infection requiring antibiotics

b

You notice that a teenager has an irregular pulse. The best action you should take includes: a. reading the history and physical. b. assessing the apical pulse rate for 1 full minute. c. auscultating for strength and depth of pulse. d. asking whether the patient feels any palpitations or faintness of breath.

b

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which steps should the nurse include in the teaching plan? (Select all that apply.) Select all that apply. a. Applying a dry sterile dressing b. Cleansing the wound c. Managing pain d. Using cold water in the bath e. Hand washing

b, c, e

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: Select all that apply a. Avoiding total sedation, regardless of the severity of the pain. b. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain. c. Stopping acetaminophen when the pain becomes very severe. d. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. e. Avoiding polypharmacy by limiting the use of medication to one agent at a time.

b, d

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? a. Erythema b. Increased anxiety c. Drowsiness (Stupor) d. Rapid respirations

c

A postoperative patient is breathing rapidly. You should immediately: a. call the physician. b. count the respirations. c. assess the oxygen saturation. d. ask the patient if he feels uncomfortable.

c

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? a. Precordial pain b. Elevated blood pressure c. Increased pulse rate d. Dyspnea

c

What does the Braden Scale evaluate? a. The amount of repositioning that the patient can tolerate b. Skin integrity at bony prominences, including any wounds c. Risk factors that place the patient at risk for skin breakdown d. The factors that place the patient at risk for poor healing

c

Which is the priority nursing invention for a patient with hyperthermia? a. Initiating seizure precautions b. Limiting oral intake c. Removing excess clothing d. Providing a blanket

c

A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: a. Applies the patch the third postoperative day b. Applies the patch as soon as the patient reports pain c. Places the patch as close to the hip dressing as possible d. Calls the health care provider and questions the order

d

A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: a. adjunctive therapy. b. nonopioids. c. NSAIDs. d. PCA pain management.

d

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? a. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. b. No action is required by the nurse because the order is appropriate. c. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain. d. Request to have the order changed to around the clock (ATC) for the first 48 hours.

d

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: a. it has no odor. b. a culture is negative. c. the edges reveal the presence of fluid. d. it shows purulent drainage coming from the incision site.

d

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides: a. an absorbent surface to collect wound drainage. b. decreased incidence of skin maceration. c. protection from the external environment. d. moisture needed for wound healing.

d

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? a. Category/Stage IV b. Suspected deep tissue damage c. Category/Stage II d. Unstageable

d

When assessing the blood pressure of a school-age child, using an adult cuff of normal size will affect the reading and produce a value that is: a. accurate. b. indistinct. c. falsely low. d. falsely high.

d

If you are applying ice packs to cool a patient, you must ensure not to stimulate ________________.

shivering

Tissue integrity

the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes.