2539 Unit 4- interpersonal relationship, violence, personality disorders, gas exchange, community based health care

Submersion injury: Pathophysiology

- Drowning •Death from suffocation after submersion in water or other fluid medium -Near Drowning •Survival from potential drowning -Immersion syndrome •Immersion in cold water stimulation of vagus nerve & potentially fatal dysrhythmias (bradycardia)

Anticoagulation Medications

- Heparin-intravenous infusion •APTT Activated partial thromboplastin time 24-36 sec •Therapeutic: 46-70 sec •Antidote Protamine Sulfate -Coumadin --oral •PT Prothrombin Time compared with •İNR lnternational normalized ratio 0.75-1.25 •Therapeutic: 2-3 •Antidnte: Vitamin K -Overlapping Heparin & Coumadin Therapies •Coumadin takes 2-3 days to achieve therapeutic level **pt teach on Food**

PE Prognosis-Poor If

-Elevated Brain Natriuretic Peptide (BNP) -Right Ventricular dysfunction -Hypotension -RV thrombus -Elevated Troponin 1

The Impact of Pulmonary Embolus

-PE is the most common preventable cause of death in hospitalized patients -600,000 deaths/year -80 % of pulmonary emboli occur without prior warning signs or symptoms -50 % of deaths due to pulmonary emboli occur within 2 hours of embolization -Death due to massive PE is often immediate -Diagnosis can be difficult . -Early treatment is highly effective YOU WILL TAKE CARE OF PATIENTS WITH PE! **DO NOT LEAVE PT**

Obsessive Personality Disorder

-Perfectionism -Formal, serious -Orderliness a priority -Problems with decision making, -judgments -Low self-esteem -*Harsh self-evaluations* **THEY MISS THE BIG PICTURE**

Risk Factors for PE

-Surgery -MI, heart failure -Obesity -Advanced age *Oral contraceptives, estrogen therapy* -Pregnancy, childbirth -Inherited thrombophilias - Certain cancers producing coagulation factors **ORAL CONTRACEPTIVE & SMOKING = HIGH RISK OF PE**

*DVT History*

-Symptoms in the calf alone are often the presenting manifestation of significant proximal vein involvement, while some patients with whole leg symptoms are found to have isolated calf vein DVT. -Recent potential precipitating conditions -Underlying conditions: i.e, cancer, collagen-vascular disorders -Medications

*Violence Against Pregnant Women*

-Time of excalating violence in already troubles relationship -Factors leading to battering during pregnancy -Threats to maternal and fetal well-being -signs of abuse emerging during pregnancy

Clinical Manifestations

-Usually very sudden -Hemoptysis-Bloody sputum -Dyspnea*** -Pleuritic chest pain*** -Low-grade temperature* -Anxiety, -sense of impending doom II -Change in mental status-becomes unresponsive - Cough - Tachycardia*** **Respiratory Alkalosis**

Diagnostic Tests

-V / Q scan or CT scan of chest - check lungs for areas of infarction; lack of blood flow -D-dimer lab test (fibrin by products in bloodstream- elevated in PE and DVT) -Troponin test to rule out myocardial ischemia! **D-dimer is not to diagnose heart failure, troponin is not to diagnose PE** **For PE: ventilation perfusion scan spiral CT scan d-dimer troponin**

Respiratory

.•Vascular resistance causes heart to pump harder to move the blood into the lungs which leads to right venticular enlargement and eventually congestive heart failure **End stage lung disease is the major cause of death*

**Pulmonary Embolus Prevention**

1. Minimize stasis by leg elevation 2. Urge passive and active range of motion in the immobile older person 3. Encourage early postoperative ambulation 4. Place elastic compression stockings and pneumatic calf compression boots on the postoperative patient 5. DVT prophylaxis- SQ Heparin or Low Molecular Weight

5 Normal Age-Related Changes in Lung Structure and Function

1. Stiffening of elastin and the collagen Connective tissue supporting the lungs 2. Dilated alveoli resulting in increased alveolar diameter 3.Decreased alveolar surfaces available for gas exchange 4. Increased chest wall stiffness 5. Stiffening of the diaphragm **respiratory acidosis**

What is a Pulmonary Embolism?

:An occlusion of a portion of the pulmonary vascular bed by an embolus consisting of a thrombus.

*Primary Survey*

A: airway B: breathing . C: circulation D: disability "fractures" "deformaties" E: exposure

PE Arterial Blood Gases (ABG's)

Arterial blood gas (ABG) measurements and pulse oximetry have a limited role in diagnosing PE. ABG's usually reveal hypoxemia. hypocapnia, and respiratory alkalosis. This is related to client's response to PE event.

Description of being "treatment resistant"

Changes evolve slowly

ARDS

Decrease O2 in blood despite increased giving more and more O2

Violence Against Older Womern

Defined as intentional actions that cause harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder . -Physical abuse -Neglect -Emotional abuse -Sexual abuse -Financial/exploitation abuse

Prevention of ARDS

Determined by risk factors greatest risk factor

Nursing Management

ID risk factors Prevent thrombus formation by ambulating patients, turning, applying pneumatic stockings, avoiding prolonged sitting, being vigilant about central venous catheter removal

Prevention of Infections

Limiting exposure to persons with respiratory infections -Adequate rest - immunizations

DVT Physical Exam

Many patients are asymptomatic, however, the history may include the following: •Edema principally unilateral, is the most specific symptom. Massive edema with cyanosis and ischemia (phlegmasia cerulea dolens) is rare. •Leg pain occurs in 50 % of patients , but this is entirely nonspecific. Pain can occur on dorsiflexion of the foot (Homans sign).

Dependent Personality Disorder

Need to be taken care of Submissive Submissive Difficulty in decision making Separation anxiety Impaired self-confidence Tend to seek out dominant partners View themselves as "dumb" or inadequate

Who is part of the core collab team?

Nurse Case manager Social worker -must assess pts UNIQUE NEEDS

**Digestive medications include:**

Pancreatic enzymes Histamine-2 receptor blockers Proton-pump inhibitors vitamin A,D,E, K Iron Ursodiol

Assessment

S/S nonspecific . VS LOC Neuro Gl Skin

Skin and Reproductive

Skin: -Increased levels of sodium and chloride in sweat -Skin has a salty taste •Reproductive: -Obstruction of seminal vesicles in males which can lead to sterility -Abnormally thickened cervical mucous in females can lead to fertility difficulties

Emergency Treatment

Treatment is supportive- Increase oxygen administration and optimize tissue perfusion!! -*Oxygen-check 02 saturation; ABGs; Give oxygen*! -Analgesics- pain relief, vasodilate; decrease HR -Pulmonary pressures- is there increased pulmonary hypertension pressure? -Cardiac output- What is the BP? -Cardiac rhythm- is there a regular rhythm and normal rate?

Hypothermia manifestations and complication

Vary dependent upon core temp •Mild (93.2'F -96.8 F)Lethargy, confusion, behavior changes, minor HR changes, vasoconstriction •Moderate (86 F-93.2 F) Rigidity, dec HR, dec RR, dec BP, hypovolemia, metabolic & resp acidosis profound vasoconstriction, rhadomyloysis •*Shivering usually disappears at 92'F Profound/(Severe) (<86 F)* •Person appears dead-attempt to re-warm to 90°F •Reflexes & vitals very slow •Profound bradycardia, asystole 64.4 F, or Vfib 71.6 F

Rapid Change in Condition: PE

What to do: -Raise the HOB -Stay with the client -Check 02 sat -Give O2 Check BP,P -Call healthcare provider, rapid response team *Respiratory ICU Charge nurse comes, Raise HOB into Fowler's/high Fowlers position if able to**

Treatment of DVT

contraindication to, or a failure of, recommended when there is a Inferior vena cava filter placement is anticoagulant risk for, proximal vein therapy in an individual with, or at high thrombosis or PE.

*Elder Abuse*

•**Maltreatment of older adults by family members or caregiver** •Physical and sexual abuse •Psychological abuse •Neglect •Financial exploitation •Denial of adequate medical treatment . •**Most victims are women, over age 75 . •Abuser may live with victim, be related to victim, and may have legal and/or psychological problems themselves**

*Respiratory Interventions*

•**Postural Drainage and CPT 1 to 3 times a day before meals** -Nebulizer treatments- increases airway flow and stimulated mucous clearance -Cough & deep breathe -Exercise -Antibiotics-may require higher and prolonged courses.

Intimate Partner Violence

•**Violence is a learned behavior that without intervention is self- perpetuating** • Children who witness one parent abuse another are more likely to become delinquents or batterers themselves-they see abuse as an integral part of a close relationship •Children who witness IPV are at risk for developing psychiatric disorders, posttraumatic stress disorder (PTSD), developmental problems, school failure, violence against others, and low self-esteem •Children deprived of their basic physical, psychological, and spiritual needs do not develop healthy personalities

Implementation,

•*Enhance cardiac output* - Monitor, record VS, apical pulse at least every 2 hours -*Monitor urine output* -Assess LOC at least every 4Monitor PAP , CVP , CO every 1-4 hours Assess heart and lung sounds frequently -Weigh daily at same time -Maintain IV fluids as ordered -Analgesics, sedatives, neuromuscular blockers as ordered **And vacation sedation- blocker is stopped first**

Management of the Patient With Intra- Abdominal injuries # 2

•*Ensure airway, breathing, and circulation •Immobilize cervical spine* •Continually monitor the patient •Document all wounds •*If viscera are protruding, cover with sterile, moist saline dressing* •Hold oral fluids (NPO) •*NG to aspirate stomach contents* •Tetanus and antibiotic prophylaxis •Rapid transport to surgery if indicated

Nutritional Interventions

•*High calorie well balanced diet* • Moderate fat intake •Supplemental nutrition such as "boost" •Night time supplemental feeding via g-button •Acid suppression medications- GER can worsen lung function •**Pancreatic enzymes with every meal/snack Vitamin- water soluble ADEK** •Increase of oral intake especially during the summer and include increase intake of sodiunm •Monitor stools for effectiveness of enzymes.

Nonpharmacologic Therapy

•*Mechanical ventilation* •*Artificial airways* •Proper nutrition •Adequate amounts of fluids •Other clinical therapies

**Shaken Baby Syndrome**

•*Non-accidental head trauma* •Sudden acceleration/deceleration causes deformation of the skull and movement of the brain •Brain strikes part of the skull, causing bruising of the brain •Hemorrhages can occur from tearing of small arteries due to shearing forces •**Different kind of child abuse: -Frequently, there is no intent to harm baby -Occurs because frustrated parent can't get baby to stop crying**

*Personality Disorders*

•*Personality becomes disordered: -Patterns exaggerated, inflexible, maladaptive -Manipulation, narcissism, impulsiveness -Lack of insight, fail to accept consequences -Some able to maintain relationships, careers* •*individuals with PD often diagnosed with more than one*

**Onset and Clinical Course**

•*Personality disorders persist throughout young and middle adulthood, but diminish in the 40s and 50s* •**Antisocial personality disorder** -Less likely to engage in criminal activity -May have substance abuse problems -Disregard feelings of others •Borderline personality disorder -Decreased impulsive behavior -Increased adaptive behavior -*More stable relationships by 50 years of age*

Antisocial Personality Disorder

•*Pervasive pattern of disregard for and violation of the rights of others using deceit and manipulation* -Psychopathy, sociopathy or dissocial personality disorder -Prison populations - 75 % diagnosed with antisocial personality disorder -Peaks in the 20s and diminish after 45 years in many individuals •*Ego-centric behavior: pleasure-seeking and unlawful behaviors* -Lack of empathy and remorse -Antagonism and disinhibition -Seen in more men than women

Key Components of Community - Based Care # 1

•*Promoting and maintaining health of individual and family* - Self-care •*Preventive care within content of community culture • teach preventative care at every level is called "Upstream thinking"

*Personality Disorder*

•*Three common traits with all types of PDs* -Manage stress by attempting to change the environment rather than themselves -Fail to assume responsibility for the consequences of their actions -Illustrate a lack of understanding as to how their behavior affects others •Personality disorders are organized according to clusters around a predominate type of behavior pattern

Environmental Emergencies: Heat Stroke

•A failure of heat-regulating mechanisms •Types: -Exertional: occurs in healthy individuals during exertion in extreme heat and humidity -Hyperthermia: the result of inadequate heat loss •Older adults, very young people, ill or debilitated people, and persons taking some medications are at high risk •Can cause death

Diagnostic Tests for ARDS

•ABG analysis to determine oxygen . •Chest x-ray to determine fluid in lungs •*Blood tests such as CBC, blood chemistry, and blood cultures* •Sputum culture to determine cause of infection

SAVE Model Screening Protocol

•ASK direct questions in a nonjudgmental way -Begin by normalizing the topic to the woman. -Make continuous eye contact with the woman. -Stay calm; avoid emotional reactions to what she tells you. -Never blame the woman, even if she blames herself. -Do not dismiss or minimize what she tells you, even if she does. -Wait for each answer patiently. -Do not rush to the next question. -Do not use formal, technical, or medical language. -Avoid using leading questions; be direct and to the point. -Use a nonthreatening, accepting approach.

Overview of Abuse

•Abuse: wrongful use, maltreatment of another -**Perpetrator typically someone the person knows** . •Victims across lifespan: spouses, partners, children, elders •Evidence of physical injuries requiring medical attention •Psychological injuries with broad range of responses

Violence Against Older Women

•Accurate detection and assessment of abuse in older women are essential duties of all nurses •Screening to determine what client has done to attempt to resolve abuse and effectiveness of strategies •Nurses should build a sense of trust with client: -Listen carefully -Non-judgmental -Stay current in knowledge of referral resources -overprotective partner -Delay in seeking medical treatment

*Rape*

•Acquaintance rape survivors report similar levels of depression anxiety, complications in subsequent relationships, and difficulty attaining pre-rape levels of sexual satisfaction to those reported survivors of stranger rape

Rape

•Act of violent, aggressive assault •Motives for rape include anger, power, eroticized cruelty •Statutory rape: -Sexual activity between an adult and a person under age 18, even if the activity is consensual •Acquaintance rape -Forced sex by known person . •Date rape -Rape that occurs during a dating relationship or marriage without consent of a partner

Intimate Partner Violence

•Actual or threatened physical or sexual violence, or psychological/emotional abuse -**it includes threatened physical or sexual violence when the threat is used control a person's actions** •Other descriptive terms: -Domestic abuse, domestic violence . -Gender-based violence, spouse abuse -Battering, rape

Management of the Patient With Substance Abuse

•Acute alcohol intoxication: a multisystem toxin -Alcohol poisoning may result in death -Maintain airway and observe for CNS depression and hypotension -*Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated* - Use a nonjudgmental, calm manner -May need sedation if noisy or belligerent -Examine for withdrawal delirium, injuries, and evidence of other disorders **HYPOGYCEMIA SAME BEHAVIORS AS DRUNK**

Pharmacologic Therapy for PE

•Anticoagulant therapy -Heparin bolus then infusion - Warfarin5-7 days before heparin discontinued -Warfarin therapy may be continued 3 to 6 months after discharge to prevent the formation of another pulmonary embolus -*Preventative med does not dissolve the clot* •Fibrinolytic therapy- *DISSOLVES CLOT*

Artificial Airways,

•Aspirating secretions through a catheter -Sterile technique -Open-tipped, whistle-tipped -Yankauer device for oral suctioning •Intubation, tracheostomy cause excessive secretions •*Nursing decision to suction* - Based on clinical need, not fixed schedule >Suctioning irritates mucous membranes

Genetics

•Autosomal recessive gene that varies by race. •Gender is not a factor. •*The median life expectancy is 37 (2009).* •Parents with the recessive gene have a 1 in 4 chance with every pregnancy to have a child with CF •Caused by a defective chloride ion transport

Management of the Patient With Intra- Abdominal Injuries # 1

•Blunt trauma or penetrating injuries •Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity Laboratory śtudies, *CT scan*, abdominal ultrasound (FAST), peritoneal lavage (*CBC, H&H)*

Pulmonary medication include

•Bronchodilators with CPT - Anti-inflammatory agents - Mycolytics -CFTR agents -Antibiotics for infections • Oxygen is used with caution

**Assessment of child abuse**

•Burns or scalds with identifiable shapes •Injury is not consistent with how it happened -Skull injury sustained from baby rolling off couch when baby is not old enough to roll -Injury is too severe for fall of 20 inches . •Bruises with recognizable shapes -Belt buckle -Teeth marks •Nurses are responsible for reporting suspected child abuse with accurate and thorough documentation of assessment data

Pathophysiology of Pulmoary Emboli

•Caused by blood clot; Often originate in long veins or pelvis Also may origiñate in atria-AFIB • With occlusion, substances are released from clot resulting in constriction of regional blood vessels and bronchioles>>> results low alveolar oxygen pressure and increased pulmonary vascular resistance . •This in turn increases work load of right heart>>can result in right heart failure, decrease in systemic blood pressure and development of shock •Effects: Lung tissue infarction; low oxygen levels in arterial blood- tissue hypoxia- *brain cells die first!*

Borderline Personality

•Characteristics -Impulsivity -Unstable emotions, depression -Self-harm such as cutting -Splitting -75 % of diagnosed cases are women -Low self-esteem, intense self-criticism, disassociation -Negative affectivity, disinhibition, antagonism -**MAY BE DEVALISHED**

**Shaken Baby Syndrome** TEST QUESTIONS

•Child is usually less than 9 months old •Neurologic deficits from SBS may take several years to appear with slow recovery -Poor outcomes with intellectual disability, motor dysfunction, blindness MUST KNOW •**Classic presentation** -Intracranial hemorrha -Intraocular hemorrhag -Retinal hemorrhage **LOOK AT EYES**

**Bullying** TEST QUESTIONS

•Children who bully have low self-esteem, poor grades, poor interpersonal skills •Boys tend to show force when bullying •Children who are bullied have increased episodes of headache, stomachaches, sleep problems, anxiety, depression, suicide tendencies •Parents should work with school, child, physician to solve bullying

Cystic Fibrosis

•Chronic multisystem disorder •Affects exocrine glands 1. Affects respiratory, digestive, integumentary, and reproductive systems 2.**Transmitted by autosomal.recessive gene*

Onset and Clinical Course

•Clients with personality disorders have a higher death rate as a result of suicide •Suicide attempts •Drug and alcohol abuse •Higher divorce rates •Criminal behavior •*changes jobs frequently*

⁉️Histrionic personality disorder (TEST QUESTION)⁉️

•Clinical picture -excessive emotionality and attention seeking -Insincerit -center of attention -exaggeration of relationships •Nursing interventions -feedback about social interactions -social skills training through role-playing -exploration of strengths, assets

Schizotypal personality disorder

•Clinical picture -social and interpersonal deficits -behavioral eccentricities -cognitive or perceptual distortions -*odd appearance -inability to respond to normal social cues* **UNCOMFORTABLE IN REALTIONSHIPS** •Nursing interventions -self-care -social skills -community functioning

*Personality Disorders # 1 (MUST KNOW CLUSTERS)*

•Cluster A: odd or eccentric behavior -Paranoid personality disorder -Schizoid personality disorder -Schizotypal personality disorder

*Personality Disorders # 2 (MUST KNOW)*

•Cluster B-erratic or dramatic behaviors -Borderline personality disorder -Antisocial personality disorder -Narcissistic personality disorder -Histrionic personality disorder

*Personality Disorders # 3 (MUST KNOW)*

•Cluster C-anxious or fearful behaviors -Obsessive personality disorder -Avoidant personality disorder -Dependent personality disorder * Table 18.2-pg 343 Videbeck* QUESTIONS OVER TABLE

**Treatment**

•Combination of medication and group and/or individual therapies •Medication treatment is focused on client's symptoms -Know different medications prescribed

Implementation

•Communication is key -Listening-I hear and understand what you are saying" Being listened to can be an empowering experience for a woman who has been abused. -Communicating belief-"That must have been very frightening for you." -Validating the decision to disclose-"It must have been difficult for you to talk about this today." -Emphasizing the unacceptability of this violence-"You don't deserve to be treated this way." •Establish a safety plan Teaching guidelines 9.1 pg 315 Ricci •**ASK: What efforts have you made to change the situation? Did it work?**

**Character** Videbeck pg. 340

•Concepts about self and external world •Develops over time •Three major character traits 1.) *Self-directedness*: >Extent to which a person is responsible, reliable, resourcefull, goal oriented, and self-confident. Self-directed people are realistic and effective and can adapt to their behavior to achieve goal. >People are low in self-directedness are blaming, helpless, irresponsible, and unreliable. They cannot set and pursue meaningful goals 2.) *Cooperativeness*: > refers to the extent to which a person sees themselves as an integral part of human society. Highly cooperative people are described as empathetic, tolerant, compassionate, supportive, and principled. >People with low cooperativness are self-absorbed, intolerant, critical, unhelpful, revengeful, and opportunistic. That is that they look out for themselves without regard for the rights and feelings of others 3.) *Self-transcendence*: >Describe the extent to which a person considers themselves to be an integral part of the universe. *Self transcendence people are spiritual, and pretentious, humble, and fulfilled*. These trades are helpful with when dealing with suffering, illness, or death. >People low in self-transcendent are practical, self-conscious, materialistic, and controlling. They may have difficulty excepting suffering, loss of control, personal and material losses, and death.

Heat Stroke Manifestations & Complications

•Core temp >104 F •No perspiration •Skin hot, ashen, dry •Dec. BP •Inc. HR

The key is prevention

•DVT prophylaxis in at-risk patients is quite effective -Just do it!

Submersion Injury: Pathophysiology

•Death is caused by hypoxia secondary to aspiration & swallowing of fluid •Victims that aspirate -Fluid aspirated into pulmonary tree> PULMONARY EDEMA - HYPOXIA •Victims that do not aspirate -Bronchospasm & airway obstruction "dry drowning" HYPOXIA

Hypothermia: Pathophysiology

•Definition Core temperature less than 95 F (35°C) •core temp < 86 F - severe hypothermia . •Core temp <78 F- death •Heat produced by the body cannot compensate for cold temps of environment -55 % -60 % of all body heat is lost as radiant energy >Head, thorax, lungs •Dec body temp -> peripheral vasoconstriction→ shivering & movement → coma results <78

**ARDS Risk Factors**

•Direct insults - Aspiration of gastric contents -Inhalation injuries >Smoke inhalation >Salt water inhalation •Indirect insults -Overall body sepsis - Trauma -Gastrointestinal infections

Bites & Stings:Pathophysiolgy

•Direct tissue damage is a product of: -Animal size -Characteristics of animal's teeth -Strength of jaw -Toxins released Death is due to: -Blood loss -Allergic reactions -Lethal toxins

Clinical Manifestations of ARDS

•Dyspnea, tachypnea, agitation, confusion and lethargy are early signs • Progressive respiratory distress •Hypoxia

SAVE Model Screening Protocol

•EVALUATE, educate, and refer this client by asking her -What type of violence was it? -Is she now in any danger? -How is she feeling now? -Does she know that there are consequences to violence? -Is she aware of community resources available to help her?

**Shaken Baby Syndrome**

•Educating parents/caregivers on stress management, alternative means of handling crying infant can help prevent SBS •Teaching dangers of shaking a baby should begin during the prenat period

Elder Abuse

•Elder abuse may occur when an older spouse is taking care of another •If abuser is an adult child, twice as likely to be a son as a daughter •Reluctant to report abuse because abuser is family member, fear of losing support, or being moved to institution . -*Elder person may have bruises or fractures, may lack eyeglasses or hearing aids (needed medical equipment), may be denied food water, may be restrained in bed*

Violence Against Older Women

•Emotional Consequences -Depression Insomnia -Chronic pain -Difficulty trusting others -Low self-esteem -Thoughts of suicide -Substance abuse -Anger issues -Atypical chest pain -Other somatic symptoms

Psychosocial Support

•Emotional support for fatal inherited disease -*Referral to genetic counseling* - Referral to support groups -Assistance in dealing with frequent re-hospitalizations -Assistance with financial issues -Assistance with learning all the daily treatment requirements. •*Education for medication administration- oral enzymes to an infant for all meals. •Education for chest therapy* •Referral to nutritionist

Human Trafficking

•Enslavement of a person who is forced into sex work or various forms of labor . •Women and children are primary victims . •Poverty and lack of economic opportunity make women and children risks for human trafficking •Victims are at risk for rape, physical injury, fractured bones, HIV/AIDs, STls, torture •Identifying victims of human trafficking Box 9.6 pg 323 Ricci

**Etiology and Risk Factors for PE**

•Etiology -Deep veins of legs -Fatty tissue •Risk factors -DVT**** Stasis of blood flow - Vessel wall damage - Altered blood coagulation- clotting disorders -Prolonged immobility -Dehydration -Trauma - Hip, femur fractures

Evaluation

•Expected outcomes may include: -*Client maintains oxygen saturation greater than 90 % -best indicator !!* -Vital signs remain within acceptable limits -Client 's airway remains clear - Client has no complications secondary to hypoxia -ABG results indicate acid-base balance maintained

Hypothermia Causes

•Exposure to cold temperatures -Inadequate clothing, inexperience -Physical exhaustion •Wet clothes in cold temperatures •Immersion in cold water/near drowning •Age/current health status predispose

Primary Survey

•Exposure/Environmental control -Remove clothing -Provide temperature control-avoid hypothermia

Family Violence

•Family violence: spouse battering; neglect, and physical, emotional, or sexual abuse of children; elder abuse; marital rape •**Common characteristics regardless of type of abuse . -Social isolation -Abuse of power, control -Alcohol, other drug abuse -Intergenerational transmission process**

Types of Abuse Sexual abuse

•Forcing the woman to have vaginal, oral, or anal intercourse against her will •Biting the victim's breasts or genitals •Shoving objects into the victim's vagina or anus •Forcing the woman to do something sexual that she finds degrading or humiliating •Forcing the victim to perform sexual acts on other people or animals

⁉️Narcissistic Personality Disorder (TEST QUESTION)**⁉️

•Grandiosity •Need for admiration •Lack of empathy •Arrogant or haughty attitude •Superior view •Fragile, vulnerable self-esteem •Ambitious •Attention-seeking behaviors •More men than women are diagnosed •May have substance abuse, eating disorders •Extreme reliance on others' perceptions and/or inflated sense of self •Antagonism **NEEDS ADMIRATION** 🚫🚫DOES NOT WANT TO BE THE CENTER OF ATENTION 🚫🚫

Assessment

•Hesitant to talk openly to nurse •Fearful •Withdrawn •Depressed •Helpless

Assessment of elder abuse

•Hidden or untreated injuries •Injury incompatible with explanation -Cuts -Lacerations -Bruises -Welts -Burns >Scalding, cigarette, friction burns on wrists and ankles from restraint •Physical neglect -Pervasive smell of urine or feces -Dirt -Rashes -Sores -Inadequate clothing

Novelty-Seeking Temperament

•High Novelty-Seeking Temperament - Quick tempered -Curious -Easily bored -Impulsive -Extravagant -Disorderly •Low Novelty Seeking Temperament -Slow tempered -Stoic -Reflective -Frugal -Reserved -Orderly

**Harm Avoidance**

•High harm avoidance characteristics -Fear of uncertainty -Social inhibition -Shyness with strangers •Low harm avoidance characteristics -Unresponsiveness to potential harm or danger

**Workplace Violence**

•High stress environments are at risk for workplace violence -Emergency departments -Intensive Care Units •Reports of rape, assault, and homicide are increasing according to the Joint Commission •Workplace violence can involve assault on nursing staff by patients, or visitors, but can also involve assault on patients/visitors by nursing staff •Recognition and responding to warning flags is important to reducing workplace violence -Behavioral changes -Drug/ETOH abuse -Personal crisis -Employment termination

Persistent

•Highly persistent -Hardworking, ambitious overachievers -Respond to fatigue or frustration as a personal challenge -Persevere •Low persistence -Inactive, indolent, unstable, erratic -Give up easily when frustrated -Rarely strive for higher accomplishments

Types of Abuse Physical abuse

•Hitting or grabbing the victim so hard that it leaves marks •Throwing things at the victim •Slapping, spitting at, biting, burning, pushing, choking, or shoving the victim •Kicking or punching the victim, or slamming her against things •Attacking the victim with a knife, gun, rope, or electrical cord •Controlling access to health care for injury

Reward Dependence

•How a person responds to social cues •High reward dependence -Tender-hearted -Sensitive Sociable -Socially dependent -Dependent on approval from others . •Low reward dependence -Practical -Touch-minded -Cold -Socially insensitive -Social withdrawal

Complications of Crush Injuries

•Hypovolemic shock •Paralysis of body part •Erythema and blistering •Damage to body part •Renal dysfunction

Collaborative Plan of Care for ARDS

•ID underlying cause •Intubation Ventilator support •Circulatory support •Nutritional support •*PEEP-improves oxygenation by preventing alveolar collapse; use allows lower FiO?2* (sometimes) •With peep, use low tidal volume • Hemodynamic monitoring

Assessment: of abuse

•If abuse is suspected, isolate client from abuser immediately to provide privacy •Ask direct and indirect questions about abuse •If abuse is detected: -Educate client about the connection between the violence and symptoms -Help the client acknowledge what has happened and begin to deal with the situation -Offer referrals to get the help that will allow healing to begin

*Personality Definition*

•Ingrained enduring pattern of behaving and relating to self, others, environment •*Perceptions, attitudes, emotions* •Usually not consciously aware of own personality •Personality disorders: traits inflexible and maladaptive; significant interference with functioning cause of emotional distress **you can tell personality by 18**

Environmental Emergencies: Hypothermia

•Internal core temperature is 35 C or less •Older adults, infants, persons with concurrent illness, homeless people, and trauma victims are at risk •Alcohol ingestion increases susceptibility •Hypothermia may be seen with frostbite, and treatment of hypothermia takes precedence •Physiologic changes in all organ systems •Monitor continuously

Nursing Management: Assessment of abuse

•Listen attentively •Show interest in concerns of the client •Communicate support through non-judgmental attitude -"No one deserves to be abused" •**Look for subtle clues of abuse -" Bruises on chest and/or arms"** -Mental Health disorders-depression, anxiety, PTSD, substance abuse, eating disorders

Changes That Can Affect Pulmonary Function

•Loss of muscle tone -Exacerbated by deconditioning - Obesity -Sedentary lifestyle •Increased thoracic rigidity and osteoporotic changes to the spine (kyphosis) •Deconditioning can be defineds: as the multiple, systems brought about by physical inactivity and disuse. potentially reversible changes in body

Mechanical Ventilation

•Mainstay of ARDS management -Percentage of oxygen inspired (FiO2) as low as possible •Ventilator setting -rate, tidal volume, oxygen concentration -12-15 ventilators breaths per minute initially •complications -Hospital acquired pneumonia (VAP) -barotrauma -pneumothorax -cardiovascular fact - reduced cardiac output (vasopressors) -gastrointestinal effects

Implementation,

•Maintain patent airway - Suction as needed - Obtain sputum for culture -Chest physiotherapy as ordered -**Secure endotracheal or tracheostomy tube** -*Maintain adequate hydration- or secreations become thick*

Management of the Patient With Ingested Poisons

•Measures to remove the toxin or decrease its absorption -Use of emetics -Gastric lavage -Activated charcoal -Cathartic when appropriate -Administration of specific antagonist as early as possible -Other measures may include diuresis, dialysis or hemoperfusion •*Corrosive agents such as acids and alkalines cause destruction of tissues by contact. Do not induce vomiting with corrosive agents*

Myths and Facts (Table 9.2 pg 307 Ricci)

•Myths: -Women who are raped get over it quickly. -Most rape victims tell someone about it. -Once the rape is over, a survivor can again feel safe in her life. -If a woman does not want to be raped, it cannot happen. •Facts: -It can take several years to recover emotionally and physically from rape - the majority of women never tell anyone about it. In fact, almost 2/3 of victims never reported to the police -the victim feels vulnerable, betrayed, and insecure afterward -woman can be forced an overpowered by most men

*Passive-aggressive behavior* (KNOW WHAT IT LOOKS LIKE)

•Negative atitude and pervasive pattern of passive resistance to demands adequate social and occupational performance . •May appear cooperative ingratiating, or sullen and withdrawn •Mood may fluctuate rapidly and erratically •Easily upset ror offended

Passive-Aggressive Personality Behavior

•Negative attitude, passive resistance to demands for adequate social and occupational performance •Blaming of others •Nursing interventions -Identification and expression of feelings

Dysfunctional Personality Traits

•Negative behavior toward others, •Anger and/or hostility •Irritable/labile moods •*Lack of guilt*, remorse or emotionally cold, and uncaring •Impulsive, poor judgment •Irresponsible, not accountable for own actions •*risk-taking*, thrill seeking behavior •*mistrust* •exhibitionism •dependency **EMOTIONS DEPEND ON OTHER PEOPLE** •eccentric perceptions

**Factors That Have Increased the Need for Community Health Care**

•New population trends -Aging population (Biggest reason for community health services) •Changes in federal legislations (DRGs) •Tighter insurance regulations •Decreasing hospital revenues **ex. Of Catastrophic claim is a burn patient**

Dependent Personality Disorder

•Nursing interventions -Expression of feelings -Autonomy/self-reliance -Cognitive restructuring -Problem solving **balance checkbook, plan meals, decision making skills, weekly grocery shopping**

*Avoidant Personality Disorder*

•Nursing interventions -Self-affirmations -Positive self-talk -Support and reassurance -Reframing/decatastrophizing -Social skills training

⁉️Narcissistic Personality Disorder (TEST QUESTION)⁉️

•Nursing interventions -Self-awareness skills to avoid anger and frustration -Matter-of-fact apnroach -Limit setting

PE Pathophysiology

•Only about 10 percent of emboli cause pulmonary infarction, usually in patients with preexisting cardiopulmonary disease. •Most pulmonary emboli are multiple, with the *lower lobes being involved* in the majority of cases.

Treatment of DVT

•Oral anticoagulation with warfarin should prolong the INR to a target of 2.5 (range: 2.0 to 3.0). •If oral or inconvenient, long-term therapy can be anticoagulants are contraindicated unfractionated heparin, low molecular undertaken with either adjusted-dose weight heparin. *no labs needed for lovenox*

Antisocial Personality Disorder and Nursing Process Application

•Outcome identification •Data analysis/nursing diagnoses •Intervention -*Therapeutic relationship; responsible behavior (limit setting, confrontation) -Problem solving; control of emotions (timeout) -Enhancing role performance* •Evaluation **Dx @ 18y.o**

Related Personality Disorders

•Paranoid personality disorder -Clinical picture >pervasive mistrust/suspiciousness >use of projection >*conflict with authority* •Nursing interventions -*formal, business-like approach* -involvement in plan of care -idea validation before action **DONT JOKE WITH THEM, BE THERE WHEN PLANNING CARE**

Child Abuse

•Parents who abuse children have minimal parenting knowledge and skills •May be emotionally immature, needy, incapable of meeting their own needs . •Views children as property, not as people with individual rights and feelings •**Adults that were victims of abuse as children, often abuse their own children**

**Depressive behavior** KNOW WHAT IT LOOKS LIKE

•Pattern of depressive cognitions and behaviors in various contexts •Occurs in people who have relatives that have major depressive disorder

Personality Disorders

•Personality disorder (PD) -When established personality patterns result in repeated conflicts with and impair ability to function in society -Rigid, maladaptive behaviors -Difficulty adapting to social demands, change •PDs are independent of mental disorders -Generally consistent over time and across varying situations -Manifest during adolescence

Depressive Personality Behavior

•Pervasive depressive cognitions and behaviors (less severe than major depression) pessimistic, negative thinking •Low self-esteem •Nursing interventions Safety -Involvement in activities -Factual feedback

**Cycle of Violence**

•Phase 1: Tension building -*First, LONGEST phase* -Drinking, jealousy, hostility, friction -Internalizes responsibility for reactions -Anger is legitimate •Phase 2: Acute battering - Explosion of violence -Batterer loses control physically and emotionally -Battered partner considers themselves lucky abuse was not worse -Deny seriousness of situation -Phase 3: Honeymoon -calm, loving contrite behavior -genuinely sorry behavior -victim belives partner can change -victim feels responsible for partner's behavior and well-being •the cycle increases with intensity over time

Bites & Stings Snakebites

•Pit viper, rattlesnakes, copperheads, water moccasins, coral snakes •Pit viper: hemolytic, coral: neurot •Can cause systemic reaction - Necrosis can occur • Treatment: -IV access, fluids, labs, analgesics as needed, circumference of site q30mins, tetanus prophylaxis Ice & tourniquets not recommended -*Caffeine, alcohol & smoking not recommended Remember: "red on yellow kill a fellow"*

**Management of the Patient With Poisoning**

•Poison is any substance that when ingested inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action. •Treatment goals -Remove or inactivate the poison before it is absorbed - Provide supportive care in maintaining vital organs systems - Administer specific antidotes -Implement treatment to hasten the elimination of the poison

Implementation,

•Prepare for discharge -ARDS consequence of serious illness -Maximal respiratory function *within 6 months* >May remain significantly impaired -*Avoid smoking, exposure to smoke* - Immunizations (pnemonia)

Types of Abuse Financial abuse

•Preventing the woman (or man) from getting a job •Sabotaging a current job •Controlling how all money is spent •Failing to contribute financially

Anticoagulation

•Prevention of clot propagation & development of new clots or embolization -*Does not dissolve the present clot* •Heparin -Inhibits Factor IX & potentiates the action of antithrombin Ill- Intrinsic Clotting Pathway -Inhibits thrombin-mediated conversion of fibrinogen to fibrin •Coumadin -Inhibits hepatic synthesis of Vitamin K-dependent coag factors II, VII, IX,

Types of Abuse - Emotional abuse

•Promising, swearing, or threatening to hit the victim •Forcing the victim to perform degrading or humiliating acts •Threatening to harm children, pets, or close friends •Humiliating the woman by name-calling and insults •Threatening to leave her and the children •Isolation from family and friends • Destroying valued possessions • Controlling the victim's every move

Implementation,

•Promote safety Assess signs of bleeding Report coagulation study - Keep antidote at bedside -Assess medication regime -Avoid invasive procedures -Maintain pressure on puncture , injection site -Maintain adequate fluid intake **soft tooth brush* *🚫 falls*

Implementation,

•Promote spontaneous ventilation - Assess, document >Respiratory rate, VS, O2 saturation every 15-30 minutes >Promptly report worsening data -Administer O2 as ordered, monitor response -Place in Fowler or high-Fowler -Minimize activity, energy expenditures

Other Clinical Therapies

•Prone positioning •Antibiotics •Careful fluid replacement •Attention to nutrition •**Swan-Ganz line to monitor -Pulmonary artery pressures -cardiac output** •Low-molecular-weight heparin

**Rape** ON TEST

•Rape survivors take a long time to heal •**Most suffer from PTSD -Situational crisis that survivor is unprepared to handle -May appear within 3 months of the incident but occasionally emerge years later with symptoms lasting more than a month** •SANE Nursing (https://www.forensicnurses.org/page/AboutSANE?) -Specially trained registered nurse that conducts sexual assault evidentiary exams rape victims -collect forensic evidence -Crisis intervention STI testing -Emergency contraception

Clinical manifestations of ARDS

•Rapid onset of dyspnea that usually occurs 12-48 hours after initiating event •*Arterial hypoxemia that does not respond to O2* •Chest xray reveals bilateral infiltrates resembling cardiogenic pulmonary edema

**Bullying** TEST QUESTIONS

•Repeated negative actions that are clearly malicious and unwarranted, by one or more persons directed at a victim •Can affect school performance and social relationships and have long- lasting traumatic effects such as depression, low self-esteem, anxiety, academic problems and violence later in adolescence and adult hood •Text messages, emails, social networking are used for cyberbullying •Bullies look for victims who appear shy, weak, defenseless •Children with health issues, disabilities, obesity are at risk for being bullied

Submersion Injury: Causes & Incidence

•Risk factors a -Inability to swim & entanglement with objects in water -ETOH or drug use -Trauma -Seizures -Stroke

**Date rape drugs**

•Rohypnol ("roofies) -Liquid or pill -No taste, color, odor -10 times as strong as Valium -Effects felt in 30 minutes with memory •Gamma hydroxybutyrate (GHB, "liquid ecstasy", "easy lay") -Euphoria, an out-of-body high, sleepiness, increased sex drive, and memory loss, depression, or coma -Effects felt within 15 minutes and lasts 3-4 hours-can cause unconsciousness -White powder or liquid •Ketamine ("Special K", "Vitamin K", "Super acid") -Separates perception and sensation -Combining with other drugs can be fatal

SAVE Model Screening Protocol

•SCREEN all of your clients for violence by asking: -Within the last year, have you been physically hurt by someone? -Do you feel you are in control of your life? Within the last year, has anyone forced you to engage in sexual activities? -Can you talk about your abuse with me now? -In general, how would you describe your present relationship?

Related Personality Disorders # 2

•Schizoid personality disorder -Clinical picture: >social detachment >restricted emotions >intellectual •Nursing interventions -*improved functioning in community*

Pathophysiology of ARDS

•Secondary to an inflammatory trigger, release of cellular and chemical mediators>>>injury to alveolar capillary membrane •Leads to leakage of fluid into alveolar interstitium causing pulmonary edema, damage to pneumocytes, microatelectasis •V/Q (ventilation is poor mismatch-alveolar collapse r/t inflammatory infiltrate despite good perfusion) and surfactant dysfunction •Fibrosing alveolitis, "stiff lungs', creates shunting •*Severe hypoxemia ensues*

Digestive

•Secretions of pancreatic enzymes (trypsin, amylase, lipase) are blocked •*Lack of enzymes leads absorption of proteins, cholesterols, and fats* •Fibrotic changes in pancreas may lead to changes in the islet of Langerhans, which may cause development of type 1 diabetes. •Thickened intestinal mucous may cause bowel obstruction •*Poor absorption leads to failure to thrive* •Meconium ileus may occur with a newborn. •Chronic inflammation may result in development of Crohn's disease •Thickened biliary secretion may lead to gallbladder disease and liver dysfunction

Labs

•Serial CBC •Blood cultures •Chromosomal aberration •24 hr urine/stool

**RISK FACTORS ASSOCIATED WITH SHAKEN BABY SYNDROME**

•Single parent •Young parent •Substance abuse by a parent •Any external factors present such as financial, social, or physical burdens that place stress on the parent •Premature or sick infant •Infant with colic

Avoidant Personality Disorder

•Social discomfort •Low self-esteem •Hypersensitivity to negative evaluation •Poor social skills •Unrealistic expectations related to goal achievement •Detachment and negativity

Bites & Stings

•Spider bites •Black widow -Venom is neurotoxic to humans -Symptoms progress over time 15mins- 3hrs -Can cause systemic issues •Treatment -Cool area to slow movement of toxins -Antivenin used in special at risk population •Brown recluse -Venom is cytotoxic to humans -Symptoms progress over 6hrs -2weeks -Can cause systemic issues •Treatment -Clean area, treat pain, antibiotics (why? -Surgical debridement with grafting may be necessary

**Heat Stroke**

•Strenuous activity in hot/humid environment •High fevers • Clothing that interferes with perspiration •Working in closed areas/prolonged exposure to heat •Drinking alcohol in hot environmentr

Acute Respiratory Distress Syndrome

•Sudden and progressive pulmonary edema, increasing bilateral infiltrates, *hypoxemia refractory to oxygen supplementation and reduced lung compliance* •Most often require mechanical ventilation

*Rape*

•Survivor should be provided with safe and comfortable environment for forensic examination •Nursing care -Providing supportive care -Collecting and documenting evidence -Assessing for STIs -Preventing pregnancy -Assessing for PTSD •Follow up care *Immediate counseling* •Medical treatment •Early crisis intervention (hours, days, weeks within time of incident)

**Etiology**

•Temperament -Biologic processes of sensation, association, and motivation that underlie the integration of skills and habits based on emotion -Genetic differences account for variances in temperament traits •Four temperament traits -Harm avoidance -Novelty seeking -Reward dependence -Persistence •Response patterns are intgrained by 2-3 years of age

Scope and Practice of Emergency Nursing

•The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations •Nursing interventions are accomplished interdependently in consultation or under the direction of a physician or nurse practitioner. •The emergency department (ED) staff works as a team. *ED= sicker pts treated 1st *Disaster=sicker left to die (comfort care) -black tag

Triage

•The triage nurse collects data and classifies the illnesses and injuries to ensure that the patients most in need of care do not needlessly wait. •Protocols may be initiated in the triage area. •**ED triages differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome.**

Discharge Planning

•Transition from acute care to community setting •*Begins on admission to acute care* • Collaborative care •Family participation

Environmental Emergencies: Frostbite

•Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces •Manifestations: hard, cold, and insensitive to touch, may appear white or mottled, may turn red and painful as rewarmed •The extent of injury is not always initially known. •*Controlled but rapid rewarming; 37° to 40°C circulating bath for 30-to 40-minute intervals •Analgesics for pain •Do not massage or handle, if feet are involved, do not walk **re-warming is controlled or can cause BURNS**

Poisoning

•Treatments: -Activated charcoal, gastric lavage, eye/skin alkalinization, chelating agents and antidotes irrigation, hemodialysis, hemoperfusion, urine acetylcysteine (Mucomyst) •Contraindicated (charcoal & gastric lavage): -AMS, ileus, diminished bowel sounds, ingestion of substance poorly absorbed by charcoal (alkali, lithium, cyanide)

**Financial Exploitation**

•Unpaid bills when there is enough money to pay thenm •Unusual bank activity •Checks signed by someone else •Recent changes in a will or power of attorney when elder can make own decisions •Reported missing valuables •No contact with friends or relatives •Caregiver may complain of difficulty taking care of elder •Keep elder from talking with nurse alone

Management of the Patient With Hypothermia

•Use ABCs, remove wet clothing, and rewarm •Rewarming - Active core rewarming •Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, warm peritoneal lavage - Passive external rewarming •Warm blankets and over the bed heaters Note: Cold blood returning from the extremities cardiac dysrhythmias has high levels of lactic acid and can cause potential and electrolyte disturbances. ***watch for cardiac dysrhythmias**

SAVE Model Screening Protocol

•VALIDATE the client by telling her -You believe her story. -You do not blame her for what happened. -It is brave of her to tell you this. -Help is available for her. -Talking with you is a hopeful sign and a first big step.

Abuse Profiles

•Victims -Battered woman syndrome-rarely describe selves as abused -Deliberate, repeated physical and/or sexual abuse -May feel they have a personality flaw or inadequacy -Many abused as children •Abuser -Feelings of insecurity, powerlessness, and helplessness -Refusal to share power; violence to control victinm -Childlike aggression, antisocial behavion -Possible substance abuse

Drug therapy

•Volume expanders- blood (univeral blood O-) •Inotropes -*Digoxin, Dibutamine* •Vasopressors-levaphed (norepinephrine) •Vasocnstrictors- •Immunizations, vaccines, immune globulin •Antibiotics and antivirals •Antidotes such as atropine (anticholenergic)

**Violence Against Pregnant Women**

•Women assaulted during pregnancy are at risk for: -Depression -Panic disorder -Fetal and maternal deaths -Chronic anxiety -Miscarriage -Stillbirth -Poor nutrition -Smoking and substance abuse -Delayed or no prenatal care

Secondary Survey

•five intervention -ECG - Pulse oximetry -catheterize -NGT -Labs