NUR 1109 Final Units 5-7 & Pharm

Stress refers to the consequences of the

Stressor and the persons appraisal of it

Discolored but intact skin caused by damage to underlying tissue

Suspected deep tissue injury

-uncomplicated -acceptance evident w/i 6 mths -somatic complaints-chest pain, palpitations, HA,, nausea, changes in sleep patterns, and fatigue

normal grief

factors influencing an individuals ability to cope

number, duration, and intensity of stressors the individuals past experiences the current support system available resources

is the portion of the blood (serum) that is watery and clear or slightly yellow in appearance.

Serous drainage

Factors influencing loss, grief, and coping ability

-The individual's current stage of development -interpersonal relationships and soical support networks -type and significance of the loss -culture and ethnicity -spiritual and religious beliefs and practices -prior experience with loss -socioeconomic status

Factors that may increase and individuals risk for dysfunctional grieving

-being exceptionally dependent upon the decreased -the decreased dying unexpectedly at a young age, through violence, or in a socially unacceptable manner -Inadequate coping skills or lack of social changes -lack of hope or preexisting mental health issues, such as depression or substance use disorder

legal documents that direct EOL issues

Advance directives

is a partial or total rupture (separation) of a sutured wound

Dehiscence

What are Kubler-Ross 5 stages of Grief

Denial, Anger, Bargaining, Depression, Acceptance

Generally refers to the final phase of a patient's illness when death is imminent

EOL

dehiscence that involves the protrusion of visceral organs through a wound opening

Evisceration

is the result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color reflects the type of organism present (green may indicate a pseudomonas infection).

Purulent drainage

An occlusive dressing that swells in the presence of exudate

Hydrocolloid

May be left in place up to 5 days

Hydrocolloid

Used to maintain a granulating wound bed

Hydrocolloid

May be used on infected, deep wounds

Hydrogel (Aquasorb)

Provides a moist wound bed

Hydrogel (Aquasorb)

contains serum and red blood cells. It is thick and appears reddish

Sanguineous drainage

A temporary "second skin" ideal for small, superficial wounds

Self-adhesive, transparent film

contains both serum and blood. It is watery and appears blood streaked or blood tinged.

Serosanguineous drainage

This is a loss related to a change that is part of the cycle of life that is anticipated but still may be intensely felt. This type of loss can be replaced by something different or better

Necessary Loss

Does not adhere to the wound bed

Nonadherent material

use the ________ assessment tool for sexuality

PLISSIT P: Permission LI: Limited Information SS: Specific Suggestions IT: Intensive Therapy

Ulcers whose stages cannot be determined because eschar or slough obscures the wound.

Unstageable Pressure Ulcer

Absorb exudate from the wound

Woven gauze (sponges)

-this grief implies the 'letting go' of an object or person before the loss, as in a terminal illness -individuals have the oppurtunity to start the grieving process before the actual loss

anticipatory grief

experienced before the loss happens

anticipatory loss

The client acknowledges what is happening and plans for the future

acceptance

This is any loss of a valued person, item, or status, such as loss of a job

actual loss

coping behavior that describes how an individual handles demands imposed by the environment

adaptation

the commitment and ability of the client and family to follow a given treatment regimen

adherence

stage where body functions are heightened to respond to stressors, also called fight-or-flight response. hormones (epi, norepi, cortisone) are released, which cause elevated blood pressure and heart rate, heightened mental alertness, increased blood flow to muscles

alarm stage

three stages of GAS

alarm stage, resistance stage, exhaustion stage

most facilities require that all _________ remain in place for an autopsy

all tubes

The client lashes out at other people or things

anger

can be conducted to advance scientific knowledge regarding disease processes, which can lead to the development of new therapies

autopsies

The client negotiates for more time or a cure

bargaining

includes both grief and mourning(the outward display of loss) as the individual deals with the death of a significant individual in their life

bereavement

presence of eschar that hinders healing and requires removal

black

_____ _____, a component of self-concept, refers to the way individuals perceive their appearance, size, and body structure.

body image

factors involved in coping

client's family dynamics adherence to treatment regimens role of individual

-difficult progression through the expected stages -manifestations are more severe -suicidal ideation, intense feeling of guilt, and lowered self-esteem -somatic complaints persist for an extended period of time

complicated grief

describes how an individual deals with problems (illness and stress)

coping

describes how an individual deals with problems and issues. it is behavioral and cognitive efforts of an individual to manage stress. ways are unique to an individual and can vary greatly.

coping

lack of protein puts the client at greater risk for

delayed wound healing and infection

The client has diffculty believing a terminal diagnosis or loss

denial

The client is overwhelmingly saddened over the inability to change the situation

depression

-an experienced loss that cannot be publicly shared or is not socially acceptable, such as suicide

disenfranchised grief

assist a person during a stressful situation or crisis by regulating emotional distress

ego defense mechanisms

stage where body functions are no longer able to maintain a response to the stressor and the client cannot adapt

exhaustion stage

current trends that need coping

fastest growing pop is those 65 and over declining economic status of families family violence any acute or chronic illness that disrupts the fam unit homelessness

describes the course of action the family uses to reach its goals, including members communication skills, problem solving abilities, and available resources

function

also known as "stress syndrome". hans selye developed a theory of adaptation that describes the stress reaction in three stages

general adaptation syndrome (GAS)

is the inner emotional response to loss and is exhibited in as many ways as there are individuals

grief

durable power of attorney for health care---a document that appoints someone to make medical decisions when the client is no longer able to do so on his own behalf

health care proxy

the law can require an autopsy to be performed if the death is due to ..

homicide suicide accidental death if death occurs within 24 hrs of hospital admission

comprehensive care delivery system implemented when a client is not expected to live longer than 6 mths. Further medical care aimed toward a cure is stopped, and the focus becomes, enhancing quality of life and supporting the client toward a peaceful and dignified death

hospice care

stages of wound healing

inflammation, proliferation, remodeling

begins with the injury and lasts 3 to 6 days Control bleeding with clot formation Deliver oxygen, WBC, and nutrients to the area via the blood supply

inflammatory stage

directive documents for medical treatment per the client's wishes

living wills

occurs on about day 21 and involves the strengthening of the collagen scar and the restoration of a more normal appearance. it can take more than 1 year to complete, depending on the extent of the original wound

maturation or remodeling stage

This is any loss normally expected due to the developmental processing of life. These losses are associated with normal life transitions and help to develop coping skills

maturational or developmental loss

are responsible for following federal and state laws regarding request for organ or tissue donation, obtaining permission for autopsy, ensuring the certification and appropriate documentation of the death, and providing postmortem care

nurses

includes few or no boundaries, consistent behavior or consequences

open structure

improved the quality of life of clients and their families facing EOL issues

palliative care

This is any loss defined by the client that is not obvious or verifiable to others

perceived loss

illness has altered the level of the client's health to a point that previous roles are no longer available

permanent role changes

caused by unrelieved pressure that results in ischemia and damage to the underlying tissue

pressure ulcer

Little or no tissue loss Edges are approximated, as with a surgical incision • Heals rapidly • Low risk of infection • Minimal or no scarring

primary intention

last the next 3 to 24 days Replacing lost tissue with connective or granulated tissue Contraction of the wound's edges Resurfacing of new epithelial cells

proliferative stage

healthy regeneration of tissue

red

partial thickness skin loss with exposed dermis

stage 2

stage where body functions normalize while responding to the stressor.

resistance stage

is dictatorial and strict

rigid structure

uncertainty about what is expected when assuming a role, creates confusion

role ambiguity

this develops when a person must assume opposing roles with incompatible expectations. role conflicts can be interpersonal or inter-role

role conflict

more responsibility and roles than are manageable, very common

role overload

the frustration and anxiety that occurs when a person feels inadequate for assuming a role. caregiver burden results from the accumulated stress of caring for someone else over time

role strain

• Loss of tissue • Wound edges widely separated, as with pressure ulcers and stab wounds • Increased risk of infection • Scarring

secondary intention

_____ is subjective and includes self-identity, body image, role performance, and self-esteem.

self concept

_____ is the way individuals feel and view themselves.

self concept

Individuals' sexuality and sexual health are influenced by:

self-concept body image gender identity and expression sexual orientation

is integrated into individuals' personalities as well as their general health.

sexuality and sexual orientation

expectations of others and society regarding how one should behave when sick

sick role

This is any unanticipated loss caused by an external event

situational loss

Nonblanchable erythema of intact skin

stage 1

Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, which may feel warm or cool to touch. The tissue is swollen and congested, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.

stage 1 pressure ulcer

Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow cavity. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.

stage 2 pressure ulcer

full thickness skin loss

stage 3

Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may reach, but not extend thorough the fascia below. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common

stage 3 pressure ulcer

full thickness skin and tissue loss

stage 4

Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material).

stage 4 pressure ulcer

describes changes in an individual's state of balance in response to stressors, the internal and external force that disrupt that state of balance. it can be situational or developmental and caused by sociocultural factors. it not only impairs and weakens the immune system, it is also a causal factor in numerous health conditions.

stress

the presence of ________ delays a client's return to health in the same way that the presence of a foreign body or infection delays the healing of a wound

stressors

the client will resume the role when illness resolves

temporary role change

• Widely separated • Deep • Spontaneous opening of a previously closed wound • Risk of infection • Extensive drainage and tissue debris • Closes later • Long healing time

tertiary intention

Stressors that affect self-concept include:

unrealistic expectations surgery chronic illness changes in role performance

documentation and completion of forms following federal and state laws typically includes the following

who pronounced the death and at what time consideration of and preparation for organ donation description of any tubes or lines left in or on body disposition of personal articles who was notified, and any decisions made location of identification tags time the body left facility and destination

presence of purulent drainage and slough

yellow