Chapter 28: Immobility Chapter 44: Pain Chapter 48 Skin (bradaen scale p1193) (fundamentals of nursing) Unit 6

Implications for Practice: Skin

1. When removing any adhesive dressings or tapes, gently release the skin from the tape; do not pull the tape away from the skin. Release the skin from the adhesive by pushing the skin from the adhesive. 2. To help an elder patient reposition in bed consider the use of a repositioning device and teach the patient or family caregiver how to reposition without sliding on the sheets. 3. Be diligent about assessing bony prominences where impaired skin integrity and injury to other tissues are most likely to occur. 4. Assess the medications that a patient may be taking for effect on delayed wound healing and revise outcomes in the plan of care to reflect that possibility.

Review Questions Chapter 44

1. Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10 2. A health care provider writes the following order for a patient who is opioid-naïve 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: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible 3. A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants 4. A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route 5. The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding 6. A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity. 2. Opioid tolerance. 3. Opioid addiction. 4. Opioid withdrawal. 7. A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction 8. Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep. 9. 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? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain. 10. A patient is prescribed morphine patient-controlled analgesia (PCA). Arrange the following steps for administering PCA in the correct order. 1. Program computerized PCA pump to deliver prescribed medication dose and lockout interval. 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly. 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into injection port nearest patient. 11. 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? 1. Patient's self-report 2. Behaviors 3. Surrogate (wife) report 4. Vital sign changes 12. When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage. 13. When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? 1. TENS works by causing distraction. 2. TENS therapy does not require a health care provider's order. 3. TENS requires an electrical source for use. 4. TENS electrodes are applied near or directly on the site of pain. 14. While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: (Select all that apply.) 1. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. 2. Stopping acetaminophen when the pain becomes very severe. 3. Avoiding polypharmacy by limiting the use of medication to one agent at a time. 4. Avoiding total sedation, regardless of the severity of the pain. 5. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain. 15. A postoperative patient currently is asleep. Therefore the nurse knows that: 1. The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. 3. Pain assessment is not necessary. 4. The patient can be switched to the same amount of medication by the oral route. Answers: 1. 2; 2. 1; 3. 3; 4. 2; 5. 3; 6. 4; 7. 1, 3, 4; 8. 1, 3, 5; 9. 2; 10. 2, 5, 1, 4, 6, 3; 11. 1; 12. 1, 2, 5; 13. 4; 14. 1, 5; 15. 1.

Chest Physiotherapy (CPT)

(percussion and postural drainage) is another effective method for preventing pneumonia and keeping the airways clear (see Chapter 41). It helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so he or she is able to cough and expel them. Respiratory assessment findings identify areas of the lungs requiring CPT.

Psychological Factors: Anxiety

A person perceives pain differently if it suggests a threat, loss, punishment, or challenge. For example, a woman in labor perceives pain differently than a woman with a history of cancer who is experiencing a new pain and fearing recurrence Labor usually results in a happy ending ... a baby. New pain with a history of cancer ... may evoke the thought 'Am I going to die?'

Risk Factor for Pressure Ulcer Development

A variety of factors predispose a patient to pressure ulcer formation. These factors are often directly related to disease such as decreased level of consciousness, the presence of a cast, or secondary to an illness (e.g., decreased sensation following a cerebrovascular accident). Impaired Sensory Perception. -Patients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity than those with normal sensation Impaired Mobility. -Patients unable to independently change positions are at risk for pressure ulcer development.

Routine Clinical Approach to Pain Assessment and Management ABCDE

A: Ask about pain regularly. Assess pain systematically. B: Believe patient and family in their report of pain and what relieves it. C: Choose pain control options appropriate for the patient, family, and setting. D: Deliver interventions in a timely, logical, and coordinated fashion. E: Empower patients and their families. Enable them to control their course to the greatest extent possible

Skin Associated Issues: Focus on Older Adults

Age-related changes such as reduced skin elasticity, decreased collagen, and thinning of underlying muscle and tissues can cause the older adult's skin to be easily torn in response to mechanical trauma, especially shearing forces The attachment between the epidermis and dermis becomes flattened in older adults, allowing the skin to be easily torn in response to mechanical trauma (e.g., tape removal)

Systemic Effects

All body systems work more efficiently with some form of movement.

Nursing Diagnosis: Chronic Pain

An accurate nursing diagnosis may be made only after you perform a complete assessment Have patient describe pain intensity. -Pain constant; patient verbally reports 5 on a scale of 0 to 10 Assess onset and location of pain. -Present for 7 months in lower lumbar area Observe patient behaviors. -Grimaces and grunts with movement, rubs flanks frequently; reduced movement Assess effect of pain on activities of daily living (ADLs). -Appetite poor; gets little sleep; difficulty dressing Review medical history. Previous trauma; effectiveness of past pain control measures

Ankle-Foot Orthotic (AFO) Device

Ankle-foot orthotic (AFO) devices also help maintain dorsiflexion. Patients who wear positioning boots or AFOs need to have these removed periodically (e.g., 2 hours on, 2 hours off). Apply positioning boots to prevent footdrop by maintaining the feet in dorsiflexion

Nursing Process: Pain

Apply the nursing process and use a critical thinking approach in your care of patients. thoroughly assess each patient and critically analyze findings A comprehensive assessment of pain aims to gather information about the cause of a person's pain and determine its effect on his or her ability to function.

Shear

Force exerted against the skin while the skin remains stationary and the bony structures move

Pathological Fractures

Fractures resulting from weakened bone tissue; frequently caused by osteoporosis or neoplasms

Urinary Elimination

Immobility alters a patient's urinary elimination. In the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces. When a patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters

Skin

Injury to the skin poses risks to safety and triggers a complex healing response. Your most important responsibilities include assessing and monitoring skin integrity, identifying patient risks for skin problems, identifying actual problems, and planning, implementing, and evaluating interventions to maintain skin integrity. Once a wound occurs, it is critical to know the process of normal wound healing to identify the appropriate nursing interventions.

Behavioral Indicators of Effects of Pain

Behavioral Indicators of Effects of Pain Vocalizations • Moaning • Crying • Gasping • Grunting Facial Expressions • Grimace • Clenched teeth • Wrinkled forehead • Tightly closed or widely opened eyes or mouth • Lip biting Body Movement • Restlessness • Immobilization • Muscle tension • Increased hand and finger movements • Pacing activities • Rhythmic or rubbing motions • Protective movement of body parts • Grabbing or holding a body part Social Interaction • Avoidance of conversation • Focus only on activities for pain relief • Avoidance of social contacts • Reduced attention span • Reduced interaction with environment

Anthropometric Measurments

Body measures of height, weight, and skinfolds to evaluate muscle atrophy.

Review Question Chapter 28

1. An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported as 3 on scale of 0 to 10 after medication 2. A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output 3. The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________________. 4. A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.) 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake." 5. A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy 6. An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? 1. Loss of appetite 2. Gum soreness 3. Difficulty swallowing 4. Left ankle joint stiffness 7. A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee ground-like vomitus 5. Light brown stool 8. The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for dessert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert 9. The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mm Hg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. 4. Stockings are removed every 2 hours during application. 5. Yellow light indicates SCD device is functioning. 10. A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus 11. The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension 12. To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the first postoperative day 13. Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake 14. Place the following options in the order in which elastic stockings should be applied. 1. Identify patient using two identifiers. 2. Smooth any creases or wrinkles. 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until heel is reached. 5. Assess the condition of the patient's skin and circulation of the legs. 6. Place toes into foot of the stocking. 7. Use tape measure to measure patient's legs to determine proper stocking size. 15. Which of the following are physiological outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand Answers: 1. 2, 3, 4; 2. 1; 3. Promote venous return to the heart; 4. 1, 2, 3; 5. 1; 6. 4; 7. 1, 3, 4; 8. 1; 9. 2, 3; 10. 3; 11. 1, 2, 5; 12. 2; 13. 4; 14. 1, 5, 7, 4, 6, 3, 2; 15. 3.

Orthostatic Hypotension

is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to standing position

Friction

is a force that occurs in a direction to oppose movement. The greater the surface area of the object that is moved, the greater is the friction. A larger object produces greater resistance to movement

Body Mechanics

is a term that describes the coordinated efforts of the musculoskeletal and nervous systems. Knowing how patients initiate movement and understanding your own movements requires a basic understanding of the physics surrounding body mechanics. The body mechanics applied in the lifting techniques historically used in nursing practice often cause debilitating injuries to nurses and other health care staff

Trapeze Bar

is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bedframe. It allows a patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper-arm exercises

Thrombus

is an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel (Figure 28-2). Three factors contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures) (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest) (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). These three factors are often referred to as Virchow's triad

Bed Rest

is an intervention that restricts patients to bed for therapeutic reasons. Although it is much less commonly used, health care providers most often prescribe this intervention. Bed rest has many different interpretations among health care professionals. The duration of bed rest depends on the illness or injury and a patient's prior state of health.

Activity Tolerance

is the type and amount of exercise or work that a person is able to perform without undue exertion or possible injury. Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or ADLs. Activity tolerance assessment includes data from physiological, emotional, and developmental domains

Muscle Atrophy

loss of muscle tone and joint stiffness

Body Alignment

means that an individual's center of gravity is stable. Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy. Without balance control the center of gravity is displaced.

Chronic/Persistent Noncancer Pain

not protective and thus serves no purpose, but it has a dramatic effect on a person's quality of life. Chronic noncancer pain is prolonged, varies in intensity, and usually lasts longer (typically at least 6 months) Chronic pain is a major cause of psychological and physical disability

Relief Measures

It is useful to know whether a patient has an effective way of relieving pain such as changing position, using ritualistic behavior (pacing, rocking, or rubbing), eating, meditating, praying, or applying heat or cold to the painful site. The patient's methods are ones that can often be used for treatment if appropriate to the cause of pain. Patients gain trust when they know that nurses are willing to try their relief measures. This is particularly the case in home settings. Patients gain a sense of control over the pain instead of the pain controlling them. Assessment of relieving factors also includes identification of all the patient's health care providers (e.g., internist, orthopedist, acupuncturist, chiropractor, or dentist).

Psychological Factors: Cultural

The meaning that a person associates with pain affects the experience of pain and how one adapts to it. This is often closely associated with a person's cultural background, including age, education, race, and familial factors.

Pressure Ulcer

an impairment of the skin as a result of prolonged ischemia (decreased blood supply) in tissues (see Chapter 48). An ulcer is characterized initially by inflammation and usually forms over a bony prominence. Ischemia develops when the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin.

Renal Calculi

calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia.

Idiopathic Pain

chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition

Integumentary Changes

immobility add to the harmful effect of pressure on the skin in immobilized patients. This makes immobility a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative

Trochanter Roll

prevents external rotation of the hips when a patient is in a supine position. To form a trochanter roll, fold a cotton bath blanket lengthwise to a width that extends from the greater trochanter of the femur to the lower border of the popliteal space (Figure 28-10). Place the blanket under the buttocks and roll it counterclockwise until the thigh is in neutral position or inward rotation. When the hip is aligned correctly, the patella faces directly upward

Pressure Intensity

A classic research study identified capillary closing pressure as the minimal amount of pressure required to collapse a capillary (e.g., when the pressure exceeds the normal capillary pressure range of 15 to 32 mm Hg) (Burton and Yamada, 1951). Therefore, if the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur If it blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanchable hyperemia. However, if the erythematous area does not blanch (nonblanchable erythema) when you apply pressure, deep tissue damage is probable.

Embolus

A dislodged venous thrombus, called an embolus, can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. More than 90% of all pulmonary emboli begin in the deep veins of the lower extremities

Joint Contracture

A joint contracture is an abnormal and possibly permanent condition characterized by fixation of a joint Immobility can lead to joint contractures it is imperative that nurses recognize that immobilized patients are at high risk for accelerated bone loss

Joint Contracture

A joint contracture is an abnormal and possibly permanent condition characterized by fixation of a joint. It is important to note that flexor muscles for joints are stronger than extensor muscles and therefore contribute to the formation of contractures. Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot achieve full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in patients who are permanently curled in a fetal position. Early prevention of contractures is essential

Cardiovascular

Cardiovascular nursing assessment of a patient who is immobilized includes blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis Although not all patients experience orthostatic hypotension, nurses monitor their vital signs during the first few attempts at sitting or standing (see Chapter 30), especially after periods of immobilization. Move a patient gradually during position changes and monitor him or her closely for dizziness while assessing the orthostatic blood pressures. The longer the period of immobility, the greater is the risk of hypotension when the patient stands (McCance and Huether, 2014). Also assess apical and peripheral pulses (see Chapter 31). Recumbent positions increase cardiac workload and result in an increased pulse rate. In some patients, particularly older adults, the heart does not tolerate the increased workload, and a form of cardiac failure develops. A third heart sound, heard at the apex, is an early indication of congestive heart failure. Monitoring peripheral pulses allows you to evaluate the ability of the heart to pump blood. Immediately document and report the absence of a peripheral pulse in the lower extremities to the patient's health care provider, especially if the pulse was present previously.

Atelectasis

Collapse of Alveoli

Concomitant Symptoms

Concomitant symptoms, including nausea, headache, dizziness, urge to urinate, constipation, depression and restlessness, occur with pain and usually increase a patient's pain severity. Certain types of pain have predictable concomitant symptoms. For example, severe rectal pain often leads to constipation. These symptoms are as much a problem to a patient as the pain itself.

Negative Nitrogen Balance

Condition occurring when the body excretes more nitrogen than it takes in.

Integumentary System

Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Consistently use a standardized tool such as the Braden Scale Frequent skin assessment, which can be as often as every hour and is based on patients' mobility, hydration, and physiological status, is essential to promptly identify changes in their skin and underlying tissues Consistently use a standardized tool such as the Braden Scale.

Nursing Assessment Questions: Current Pain (PQRST)

Current Pain: (Modify Assessment for Patient's Age, Cognitive Ability, Culture, Language, and Other Factors) Palliative or Provocative factors: What makes your pain worse? What makes it better? Quality: How do you describe your pain? Relief measures: What do you take at home to gain pain relief? Region (location): Show me where you hurt. Severity: On a scale of 0 to 10, how bad is your pain now? • What is the worst pain you have had in the past 24 hours? • What is the average pain you have had in the past 24 hours? Timing: Is your pain constant, intermittent, or both? U: Effect of pain: What are you not able to do because of your pain? • With whom do you live, and how do they help you when you have pain? Current Medications • Which medications/herbs are you taking now? • Are these medications and herbs effective in relieving the pain? • Which nonpharmacological treatments have you tried to relieve the pain? • Which medications have you tried in the past that worked to stop your pain? • Have you ever used recreational drugs or alcohol to alleviate pain? Activity • What level of daily exercise can you maintain with your pain? • Which type of movement increases or relieves your pain? • Which type of activities do you now avoid because of your pain?

Box 28-7 Procedural Guidelines: Applying Sequential Compression Devices and Elastic Stockings

Delegation Considerations The skill of applying elastic stockings and sequential compression devices (SCDs) can be delegated to nursing assistive personnel (NAP). The nurse initially determines the size of elastic stockings and assesses the patient's lower extremities for signs and symptoms of DVT or impaired circulation. Instruct NAP to: • Remove SCD sleeves before allowing patient to get out of bed. • Notify nurse if patient complains of pain in leg or if discoloration develops in extremities. • When applying elastic stockings, instruct patient to avoid activities that promote venous stasis (e.g., crossing legs, wearing garters). • Elevate legs while sitting and before applying stockings to improve venous return. • Take precautions and Do Not massage patient's legs. • Avoid wrinkles in elastic stockings. Equipment Tape measure, powder or cornstarch (optional), Elastic or compression stockings, SCD insufflator with air hoses attached, adjustable Velcro compression stockings/SCD disposable sleeve(s), hygiene supplies Steps 1. Identify patient using two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. 2. Assess for risk factors in Virchow's triad: a. Hypercoagulability (e.g., clotting disorders [laboratory test results], fever, dehydration) b. Venous wall abnormalities found in patient medical history (i.e., history of orthopedic surgery, atherosclerosis) c. Blood stasis (e.g., immobility, obesity, pregnancy) CLINICAL DECISION: Clinical signs of thrombophlebitis vary according to the size and location of the thrombus. Signs and symptoms of superficial thrombosis include palpable veins and surrounding areas that are tender to the touch, reddened, and warm. Temperature elevation and edema may or may not be present. Signs and symptoms of deep vein thrombosis (DVT) include swollen extremity; pain; warm, cyanotic skin; and temperature elevation. Homans' sign (pain in the calf on dorsiflexion of the foot) is no longer considered a reliable indicator (Ball et al., 2015; Grinage and Werner, 2013). 3. Assess condition of patient's skin and circulation to the legs (e.g., presence of pedal pulses, edema, discoloration of skin, skin temperature, capillary refill, presence of lesions or cuts). Assess for contraindications for use of elastic stockings or SCDs: a. Dermatitis or open skin lesions b. Recent skin graft c. Decreased arterial circulation in lower extremities as evidenced by cyanotic, cool extremities. 4. Obtain health care provider order. 5. When applying elastic stockings, use tape measure to measure patient's legs to determine proper stocking size. 6. Perform hand hygiene. Also provide hygiene to patient's lower extremities as needed. 7. Assemble and prepare equipment. 8. Explain procedure and reason for applying SCDs or elastic stockings. 9. Position patient in supine position. Elevate head of bed to comfortable level. 10. Option: When applying elastic stockings, apply a small amount of powder or cornstarch to legs provided that patient does not have sensitivity to either. Powder eases application of stockings. 11. Apply SCD Sleeve(s): a. Remove SCD sleeves from plastic cover; unfold and flatten. b. Arrange sleeve under patient's leg according to leg position indicated on inner lining of sleeve. c. Place patient's leg on SCD sleeve. Back of ankle should line up with ankle marking on inner lining of sleeve. d. Position back of knee with popliteal opening on the sleeve (see Illustration). e. Wrap SCD sleeve securely around patient's leg. Check fit of SCD sleeve by placing two fingers between patient's leg and sleeve (see illustration). f. Attach SCD sleeve connector to plug on mechanical unit. Arrows on connector line up with arrows on plug from unit (see illustration). g. Turn mechanical unit on. Green light indicates that unit is functioning. Monitor functioning SCD through one full cycle of inflation and deflation. A typical cycle is inflation for 10 to 15 seconds and deflation for 45 to 60 seconds. Inflation pressures average 40 mm Hg. h. Reposition patient for comfort and perform hand hygiene. i. Remove compression stockings at least once per shift. j. Monitor skin integrity and circulation to patient's lower extremities as ordered or as recommended by SCD manufacturer. 12. Apply Elastic Stocking: a. Turn elastic stocking inside out by placing one hand into the sock, holding toe of sock with hand. Using other hand, pull sock over hand until reaching the heel (see illustration). b. Place patient's toes into foot of elastic stocking, making sure that stocking is smooth (see illustration). c. Slide remaining portion of stocking over patient's foot, being sure that toes are covered. Make sure that foot fits into toe and heel position of stocking (see illustration) d. Slide stocking up over patient's calf until stocking is completely extended. Be sure that stocking is smooth and that no ridges or wrinkles are present, particularly behind knee (see illustration). e. Instruct patient not to roll stockings partially down because constricting ring around leg can occlude circulation. f. Instruct patient not to massage legs. g. Reposition patient for comfort and perform hand hygiene. h. Remove stockings at least once per shift. i. Inspect stockings for wrinkles or constriction. j. Inspect elastic stockings to determine that there are no wrinkles, rolls, or binding.

Osteoporosis

Disorder characterized by abnormal rarefaction of bone, occurring most frequently in postmenopausal women, sedentary or immobilized individuals, and patients on long-term steroid therapy

Range of Motion Exercises: Lower Extremities

Hip Type of Joint: Ball and socket Flexion: Move leg forward and up. Range of Degree: 90-120 Primary Muscles: Psoas major, iliacus, sartorius Extension: Move back beside other leg. Range of Degree: 90-120 Primary Muscles: Gluteus maximus, semitendinosus, semimembranosus Hyperextension: Move leg behind body. Range of Degree: 30-50 Primary Muscles: Gluteus maximus, semitendinosus, semimembranosus Abduction: Move leg laterally away from body. Range of Degree: 30-50 Primary Muscles: Gluteus medius, gluteus minimus Adduction: Move leg back toward medial position and beyond if possible. Range of Degree: 30-50 Primary Muscles: Adductor longus, adductor brevis, adductor magnus Internal rotation: Turn foot and leg toward other leg. Range of Degree: 90 Primary Muscles: Gluteus medius, gluteus minimus, tensor fasciae latae External rotation: Turn foot and leg away from other leg. Range of Degree: 90 Primary Muscles: Obturatorius internus, obturatorius externus Circumduction: Move leg in circle. Range of Degree: None Primary Muscles: Psoas major, gluteus maximus, gluteus medius, adductor magnus Knee Type of Joint: Hinge Flexion: Bring heel back toward back of thigh. Range of Degree: 120-130 Primary Muscles: Biceps femoris, semitendinosus, semimembranosus, sartorius Extension: Return leg to floor. Range of Degree: 120-130 Primary Muscles: Rectus femoris, vastus lateralis, vastus medialis, vastus intermedius Ankle Type of Joint: Hinge Dorsal flexion: Move foot so toes are pointed upward. Range of Degree: 20-30 Primary Muscles: Tibialis anterior Plantar flexion: Move foot so toes are pointed downward. Range of Degree: 45-50 Primary Muscles: Gastrocnemius, soleus Foot Type of Joint: Gliding I Inversion: Turn sole of foot medially. Range of Degree: 10 or less Primary Muscles: Tibialis anterior, tibialis posterior Eversion: Turn sole of foot laterally. Range of Degree: 10 or less Primary Muscles: Peroneus longus, peroneus brevis Toes Type of Joint: Condyloid Flexion: Curl toes downward. Range of Degree: 30-60 Primary Muscles: Flexor digitorum, lumbricalis pedis, flexor hallucis brevis Extension: Straighten toes. Range of Degree: 30-60 Primary Muscles: Extensor digitorum longus, extensor digitorum brevis, extensor hallucis longus Abduction: Spread toes apart. Range of Degree: 15 or less Primary Muscles: Abductor hallucis, interosseus dorsalis Adduction: Bring toes together. Range of Muscle: 15 or less Primary Muscles: Adductor hallucis, interosseus plantaris

Instrumental Activities of Daily Living (IADLs)

IADLs are activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting and include such skills as shopping, preparing meals, banking, and taking medications.

Hypostatic Pneumonia

Pneumonia that results from fluid accumulation as a result of inactivity. inflammation of the lung from stasis or pooling of secretions

Pressure Ulcers

Pressure ulcer, pressure sore, decubitus ulcer, and bedsore are terms used to describe impaired skin integrity related to unrelieved, prolonged pressure. The most current terminology is pressure ulcer

Postural Abnormalities

Lordosis -Exaggeration of anterior convex curve of lumbar spine -Congenital condition; temporary condition (e.g., pregnancy) -Spine-stretching exercises (based on cause) Kyphosis -Increased convexity in curvature of thoracic spine -Congenital condition; rickets, osteoporosis; tuberculosis of spine -Spine-stretching exercises, sleeping without pillows, using bed board, bracing, surgical spinal fusion (based on cause and severity) Scoliosis -Lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders -Sometimes a consequence of numerous congenital, connective tissue, and neuromuscular disorders -Approximately half of children with scoliosis require surgery Nonsurgical treatment is with braces and exercises Footdrop -Inability to dorsiflex and invert foot because of peroneal nerve damage -Congenital condition; trauma; improper position of immobilized patient -None (cannot be corrected); prevention through physical therapy; bracing with ankle-foot orthotic (AFO)

Pressure Duration

Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to duration of pressure. Both types of pressure cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death (Pieper, 2016). Clinical implications of pressure duration include evaluating the amount of pressure (checking skin for nonblanching hyperemia) and determining the amount of time that a patient tolerates pressure (checking to be sure after relieving pressure that the affected area blanches).

Musculoskeletal

Major musculoskeletal abnormalities to identify during nursing assessment include decreased muscle tone and strength, loss of muscle mass, reduced ROM, and contractures. During assessment of ROM (described earlier) you can detect muscle tone by asking the patient to relax and then passively moving each limb at several joints to get a feeling for any resistance or rigidity that may be present. You assess for muscle strength by having the patient assume a stable position and then performing maneuvers to demonstrate strength of the major muscle group

Severity

One of the most subjective and therefore most useful characteristics for reporting pain is its severity. Nurses teach patients how to use pain scales to help them communicate pain severity or intensity. Many scales are available in several languages to aid nurses when a professional interpreter is not present It is important to select the scale that is appropriate for a patient's age, language, and ability and to ensure that the patient understands how to use it. Examples of pain-intensity scales include numerical rating scales (NRSs), verbal descriptor scales (VDSs), and visual analog scales (VASs) Assessing pain intensity in children requires special techniques. Children's verbal statements are most important. Young children do not always know what the word pain means; therefore assessment requires you to use words such as owie, boo-boo, or hurt. Some unique tools are available to measure pain intensity in children. -Faces Pain Scale (FPS) (scored 0-6) -Faces Pain Scale—revised (FPS-R) (0-10) -Oucher pain scale (0-10) -Wong-Baker Faces Pain-Rating Scale (WBFPRS) (0-10) The "Oucher" uses photographs of the face of a child (in increasing levels of discomfort) to cue children into understanding pain and its severity. A child points to a face on the tool, thus simplifying the task of describing the pain. There are cultural versions of the too

Hemiplegia

One sided paralysis

Hemiparesis

One sided weakness

Pain Assessment in Nonverbal Patient

Pain Assessment in the Nonverbal Patient PICO Question: In elderly nonverbal patients, which pain-assessment tool is most effective in determining presence of pain? Evidence Summary A common misconception is that individuals who are nonverbal as a result of dementia or cognitive impairments do not experience pain (Herr et al., 2011). Patients who are nonverbal often present with atypical manifestations of pain caused by pathophysiological changes in the brain. Manifestations often include hitting, fearful expressions, combativeness, and resistance to care (Herr et al., 2011). An appointed task force of the American Society for Pain Management Nursing developed an evidence-based position statement and clinical practice recommendations for pain assessment in nonverbal patients (Herr et al., 2011). No single assessment strategy such as interpretation of behaviors, pathology, or estimates of pain by others is sufficient by itself in determining the presence of pain in a nonverbal patient. A number of tools have been developed to assess for the presence of pain in cognitively impaired adults. Although research studies have demonstrated that these tools can be used to determine the presence of pain, there has been little evidence to determine whether they can be used to identify pain intensity. In a study by Lukas et al (2013), the Abbey Pain Scale, Pain Assessment in Advanced Dementia Scale (PAINAD), and Noncommunicative Patient's Pain Assessment Instrument (NOPPAIN) were shown to enable observers to recognize the presence or absence of pain and provide a rating of pain severity in older people with impaired cognition. Application to Nursing Practice • Recommended assessment considerations: • Attempt a self-report of pain using simple yes/no responses or vocalizations or a numerical rating scale (Herr et al., 2011). • Search for potential causes of pain (Herr et al., 2011). Examples include pain associated with intravenous insertion site infiltrations, abdominal cramping and fullness, urinary retention, muscle spasm, and prolonged pressure on body parts associated with immobility. • Assume that pain is present (APP) after ruling out other problems (infection, constipation) that cause pain. • Identify pathological conditions or procedures that cause pain. • Observe patient behaviors and list behaviors (e.g., facial expressions, vocalizations, body movements, changes in interactions or mental status) that indicate pain. These vary, depending on patient's developmental level (Herr et al., 2011). • Ask family members, parents, or caregivers for a surrogate report. • Use behavioral pain assessment tools. • Use evidence-based tools to ensure appropriate pain assessment (Herr et al., 2011). • Evidence supports use of the PAINAD for assessment of pain in patients with advanced dementia (Mosele et al., 2012). • Determine the appropriate scale on the basis of individual patient needs; no one scale measures pain accurately for all groups of patients. • Vital signs are not sensitive indicators for the presence of pain. • Choose analgesic, dose, and titration on the basis of estimated intensity of pain. • For mild-to-moderate pain, confer with health care provider to give nonopioid analgesics around the clock. • After 24 hours reassess. If behaviors improve, assume that pain was the cause. • If behaviors persist, consult with physician about giving a single, low-dose short-acting opioid (e.g., morphine). Observe effect. • If behaviors continue, obtain order to titrate dose upward by 25% to 50% and observe effect. • Continue to titrate up until a therapeutic effect or bothersome adverse effects occur or if there is no benefit. • If behaviors continue after a reasonable analgesic trial, explore other potential causes.

Effects of Pain on the Patient

Pain alters a person's lifestyle and psychological well-being. For example, chronic/persistent pain causes suffering, loss of control, loneliness, exhaustion, and an impaired quality of life. To understand a pain experience, ask the patient what the pain prevents him or her from doing.

Psychological Factors: Coping Style

Pain is a lonely experience that often causes patients to feel a loss of control. Coping style influences the ability to deal with it. People with internal loci of control perceive themselves as having control over events in their life and the outcomes such as pain. They ask questions, desire information, and make choices about treatment. In contrast, people with external loci of control perceive that other factors in their life such as nurses are responsible for the outcome of events. These patients follow directions and are more passive in managing their pain. Learn to understand patients' coping resources during painful experiences so you can incorporate these into your plan of care. For example, a patient who does not ask for pain medication but shows behavioral signs of discomfort might require you to be more responsive in offering prn medications on time

Misconceptions About Pain in Older Adults

Pain is a natural outcome of growing old. -Older adults are at greater risk (as much as twofold) than younger adults for many painful conditions; however, pain is not an inevitable result of aging. Pain perception, or sensitivity, decreases with age. -This assumption is unsafe. Although there is evidence that emotional suffering specifically related to pain may be less in older than in younger patients, no scientific basis exists for the claim that a decrease in perception of pain occurs with age or that age dulls sensitivity to pain. If the older patient does not report pain, he or she does not have pain. -Older patients commonly underreport pain. Reasons include expecting to have pain with increasing age; not wanting to alarm loved ones; being fearful of losing their independence; not wanting to distract, anger, or bother caregivers; and believing that caregivers know they have pain and are doing all they can to relieve it. The absence of a report of pain does not mean the absence of pain. If an older patient appears to be occupied, asleep, or otherwise distracted from pain, he or she does not have pain. -Older patients often believe that it is unacceptable to show pain and have learned to use a variety of ways to cope with it (e.g., many patients use distraction successfully for short periods of time). Sleeping is sometimes a coping strategy; alternately, it indicates exhaustion, not pain relief. Do not make assumptions about the presence or absence of pain solely on the basis of a patient's behavior. The potential side effects of opioids make them too -dangerous to use to relieve pain in older adults. Opioids are safe to use in older adults with moderate-to-severe pain (Arnstein, 2010). Although the opioid-naive older adult is usually more sensitive to opioids, this does not justify withholding their use in pain management. Slow titration prevents potentially dangerous opioid-induced side effects. Regular, frequent monitoring and assessment of a patient's response are necessary. Adjust dose and the interval between doses when you detect side effects. If necessary, administer an opioid antagonist drug to reverse clinically significant respiratory depression. Patients with Alzheimer's disease and other cognitive impairments do not feel pain, and their reports of pain are most likely invalid. -No evidence exists that cognitively impaired older adults experience less pain or that their reports of pain are less valid than those of individuals with intact cognitive function (Herr, 2010). Patients with dementia or other deficits of cognition most likely suffer significant unrelieved pain and discomfort. Assessment of pain in these patients is challenging but possible. The best approach is to accept a patient's report of pain and treat it as you would treat it in an individual with intact cognitive function. Older patients report more pain as they age. -Even though older patients experience a higher incidence of painful conditions such as arthritis, osteoporosis, peripheral vascular disease, and cancer than younger patients, studies show that they underreport pain. Many older adults grew up valuing the ability to "grin and bear it"

Chronic Episodic Pain

Pain that occurs sporadically over an extended period of time is episodic pain. Pain episodes last for hours, days, or weeks

Key Points Chapter 28

Passive ROM exercises begin as soon as a patient's ability to move an extremity or joint is lost • Use findings from evidence-based nursing research about safe patient handling to prevent injuries to nurses and patients when moving and transferring. • Coordination and regulation of muscle groups depend on muscle tone; activity of antagonistic, synergistic, and antigravity muscles; and neural input to muscles. • Body alignment is the condition of joints, tendons, ligaments, and muscles in various body positions. • Balance occurs when there is a wide base of support, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support. • Developmental stages influence body alignment and mobility; the greatest impact of physiological changes on the musculoskeletal system is observed in children and older adults. • The risk of disabilities related to immobilization depends on the extent and duration of immobilization and the patient's overall level of health. • Immobility presents hazards in the physiological, psychological, and developmental dimensions. • The nursing process and critical thinking assist you in providing care for patients who are experiencing or are at risk for the adverse effects of impaired body alignment and immobility. • Patients with impaired body alignment require nursing care to maintain correct positioning such as the supported Fowler's, supine, prone, side-lying, and Sims' positions. • Patient movement algorithms serve as assessment tools and guide safe patient handling and movement. • Appropriate friction-reducing assistive devices and mechanical lifts need to be used for patient transfers when applicable. • No-lift policies benefit all members of the health care system: patients, nurses, and administration.

Acute/Transient Pain

Patients in acute pain are frightened and anxious and expect relief quickly Unrelieved acute pain can progress to chronic pain

Respiratory System

Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. If a patient has an atelectatic area, chest movement is often asymmetrical. Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions. Assessment findings that indicate pneumonia include productive cough with greenish yellow sputum; fever; pain on breathing; and crackles, wheezes, and dyspnea.

Factors Influencing Mobility-Immobility

Periods of immobility due to disability or injury or prolonged bed rest during hospitalization cause major physiological, psychological, and social effects

Preventing Thrombus Formation

Please read this section pp. 424-7 THOROUGHLY

Range of Motion (ROM) Exercises: Upper Extremities

Range of motion (ROM) is the maximum amount of movement available at a joint in one of the three planes of the body Assess the type of ROM exercise that a patient is able to perform Neck, cervical spine Type of Joint: Pivotal Type of Movement Flexion: Bring chin to rest on chest. Range of Degree: 45 Primary Muscle:Sternocleidomastoid Extension: Return head to erect position. Range of Degree:45 Primary Muscle: Trapezius Hyperextension: Bend head back as far as possible. Range of Degree: 10 Primary Muscle: Trapezius Lateral flexion: Tilt head as far as possible toward each shoulder. Range of Degree: 40-45 Primary Muscle: Sternocleidomastoid Rotation: Turn head as far as possible in circular movement. Range of Degree: 180 Primary Muscle: Sternocleidomastoid, trapezius Shoulder Type of Joint: Ball and socket Flexion: Raise arm from side position forward to position above head. Range of Degree:180, 45-60 Primary Muscles: Coracobrachialis, biceps brachii, deltoid, pectoralis major Extension: Return arm to position at side of body. Range of Degree : 180 Primary Muscles: Latissimus dorsi, teres major, triceps brachii Hyperextension: Move arm behind body, keeping elbow straight. Range of Degree: 45-60 Primary Muscles: Latissimus dorsi, teres major, deltoid Abduction: Raise arm to side to position above head with palm away from head. Range of Degree: 180 Primary Muscles: Deltoid, supraspinatus Adduction: Lower arm sideways and across body as far as possible. Range of Degree: 320 Primary Muscle: Pectoralis major Internal rotation: With elbow flexed, rotate shoulder by moving arm until thumb is turned inward and toward back. Range of Degree: 90 Primary Muscles: Pectoralis major, latissimus dorsi, teres major, subscapularis External rotation: With elbow flexed, move arm until thumb is upward and lateral to head. Range of Degree: 90 Primary Muscles: Infraspinatus, teres major, deltoid Circumduction: Move arm in full circle (Circumduction is combination of all movements of ball-and-socket joint.) Range of Degree: 360 Primary Muscles: Deltoid, coracobrachialis, latissimus dorsi, teres major Elbow Type of Joint: Hinge Flexion: Bend elbow so lower arm moves toward its shoulder joint and hand is level with shoulder. Range of Degree: 150 Primary Muscles: Biceps brachii, brachialis, brachioradialis Extension: Straighten elbow by lowering hand. Range of Degree: 150 Primary Muscle: Triceps brachii Forearm Type of Joint: Pivotal Supination: Turn lower arm and hand so palm is up. Range of Degree: 70-90 Primary Muscles: Supinator, biceps brachii Pronation: Turn lower arm so palm is down. Range of Degree: 70-90 Primary Muscles: Pronator teres, pronator quadratus Wrist Type of Joint: Condyloid Flexion: Move palm toward inner aspect of forearm. Range of Degree: 80-90 Primary Muscles: Flexor carpi ulnaris, flexor carpi radialis Extension: Move fingers and hand posterior to midline. Range of Degree: 80-90 Primary Muscles: Extensor carpi radialis brevis, extensor carpi radialis longus, extensor carpi ulnaris Hyperextension: Bring dorsal surface of hand back as far as possible. Range of Degree: 80-90 Primary Muscles: Extensor carpi radialis brevis, extensor carpi radialis longus, extensor carpi ulnaris Abduction: Place hand with palm down and extend wrist laterally toward fifth finger. Range of Degree: Up to 30 Primary Muscles: Flexor carpi radialis, extensor carpi radialis brevis, extensor carpi radialis longus Adduction: Place hand with palm down and extend wrist medially toward thumb. Range of Degree: 30-50 Primary Muscles: Flexor carpi ulnaris, extensor carpi ulnaris Fingers Type of Joint: Condyloid hinge Flexion: Make fist. Range of Degree: 90 Primary Muscles: Lumbricales, interosseus volaris, interosseus dorsalis Extension: Straighten fingers. Range of Degree: 90 Primary Muscles: Extensor digiti quinti proprius, extensor digitorum communis, extensor indicis proprius Hyperextension: Bend fingers back as far as possible. Range of Degree: 30-60 Primary Muscles: Extensor digitorum Abduction: Spread fingers apart. Range of Degree: 30 Primary Muscles: Interosseus dorsalis Adduction: Bring fingers together. Range of Degree: 30 Primary Muscles: Interosseus volaris Thumb Type of Joint: Saddle Flexion: Move thumb across palmar surface of hand. Range of Degree: 90 Primary Muscles: Flexor pollicis brevis Extension: Move thumb straight away from hand. Range of Degree: 90 Primary Muscles: Extensor pollicis longus, extensor pollicis brevis Abduction: Extend thumb laterally (usually done when placing fingers in abduction and adduction). Range of Degree: 30 Primary Muscles: Abductor pollicis brevis Adduction: Move thumb back toward hand. Range of Degree: 30 Primary Muscles: Adductor pollicis obliquus, adductor pollicis transversus Opposition: Touch thumb to each finger of same hand. Range of Degree: None Primary Muscles: Opponens pollicis, opponens digiti minimi

Disuse Osteoporosis

Reductions in skeletal mass routinely accompanying immobility or paralysis.

Table 44-5 Classification of pain by location

Superficial or Cutaneous -Pain resulting from stimulation of skin -Pain is of short duration and localized. It usually is a sharp sensation. -Needlestick; small cut or laceration Deep or Visceral -Pain resulting from stimulation of internal organs -Pain is diffuse and radiates in several directions. Duration varies, but it usually lasts longer than superficial pain. Pain is sharp, dull, or unique to organ involved. -Crushing sensation (e.g., angina pectoris); burning sensation (e.g., gastric ulcer) Referred -Common in visceral pain because many organs themselves have no pain receptors (The entrance of sensory neurons from affected organ into same spinal cord segment as neurons from areas where individual feels pain causes perception of pain in unaffected areas.) -Pain is in part of body separate from source of pain and assumes any characteristic. -Myocardial infarction, which causes referred pain to the jaw, left arm, and left shoulder; kidney stones, which refer pain to groin Radiating =Sensation of pain extending from initial site of injury to another body part -Pain feels as though it travels down or along body part. It is intermittent or constant. -Low back pain from ruptured intravertebral disk accompanied by pain radiating down leg from sciatic nerve irritation

Tissue Tolerance

The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures. Systemic factors such as poor nutrition, increased aging, hydration status, and low blood pressure affect the tolerance of the tissue to externally applied pressure.

Quality

There is no common or specific pain vocabulary in general use. Patients describe pain in their own way. A study conducted in 1990 showed that Hispanics, American Indians, blacks, and whites all rated pain as the most intense term, followed by hurt; ache was the least intense The research is dated, but it shows the importance of not assuming that one patient perceives pain differently than another only on the basis of cultural background. Assess the terms that patients use to describe their discomfort and then always use these words consistently to obtain an accurate report. For example, say, "Tell me what your discomfort feels like." The patient may describe the pain as crushing, throbbing, sharp, or dull. For example, if it is dull, when you return to the patient, ask if it is still "dull." It is always more accurate to have patients describe the pain in their own words whenever possible. There is some consistency in the way people describe certain types of pain. The pain associated with a myocardial infarction is often described as crushing or viselike; whereas the pain of a surgical incision is often described as dull, aching, and throbbing, indicating nociceptive pain. Neuropathic pain is usually burning, shooting, or electric-like. When a patient's descriptions fit the pattern forming in the assessment, you then make a clearer analysis of the nature and type of pain. This leads to more appropriate pain management because you treat nociceptive and neuropathic pain differently.

Characteristics of Dark Skin with Impaired Integrity

To assess a dark-skinned patient for the presence of a category/stage I pressure ulcer, the following should be considered: assess the skin in a well-illuminated setting (i.e., a well-lit environment) Color • Color remains unchanged and does not blanch when pressure is applied. • If patient previously had a pressure ulcer, that area of skin might be lighter than original color. • Localized areas of inflammation may take on an eggplant (purplish-blue or violet) color rather than appearing reddened. Temperature • Circumscribed area of intact skin may be warm to touch. As tissue changes color, intact skin feels cool to touch. • Inflammation is detected by making comparisons to surrounding skin. Appearance • Edema may occur with induration and appear taut and shiny. • Injured skin with a stage I pressure ulcer might show low resilience. Document tissue resilience: tissue on palpation is boggy or mushy when compared to surrounding skin. Palpation • Surrounding area may be sensitive or tender to touch or may be hard or lumpy on palpation.

Elimination

To determine the effects of immobility on elimination, assess the patient's total intake and output each shift and every 24 hours. Compare the amounts over time. Determine that the patient is receiving the correct amount and type of fluids orally or parenterally (see Chapter 42). Inadequate intake and output or fluid and electrolyte imbalances increase the risk for renal system impairment, ranging from recurrent infections to kidney failure. Dehydration also increases the risk for skin breakdown, thrombus formation, respiratory infections, and constipation. Immobility impairs gastrointestinal peristalsis. Assessment of bowel elimination status includes the adequacy of a patient's dietary choices, bowel sounds, and the frequency and consistency of bowel movements (see Chapter 47). Accurate assessment enables you to intervene before constipation and fecal impaction occur.

Aggravating and Precipitating Factors

Various factors or conditions precipitate or aggravate pain. Ask a patient to describe activities that cause or aggravate pain such as physical movement, positions, drinking coffee or alcohol, urination, swallowing, eating food, or psychological stress. Also ask them to demonstrate actions that cause a painful response such as coughing or turning a certain way. Some symptoms (depression, anxiety, fatigue, sedation, anorexia, sleep disruption, spiritual distress, and guilt) cause worsening of pain or may be aggravated by it. Assess for these associated symptoms and evaluate their effects on the patient's pain perception. After identifying specific aggravating or precipitating factors, it is easier to plan interventions to avoid worsening the pain.

Behavioral Effects of Pain

When a patient has pain, assess verbalization, vocal response, facial and body movements, and social interaction. A verbal report of pain is a vital part of assessment. You need to be willing to listen and understand. When a patient is unable to communicate pain, it is especially important for you to be alert for behaviors that indicate it

Urinary Stasis

When a patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters increases risk of UTI

Footdrop

When footdrop occurs, the foot is permanently fixed in plantar flexion. Ambulation is difficult with the foot in this position because the patient cannot dorsiflex the foot A patient with footdrop is unable to lift the toes off the ground. Patients who have suffered CVAs with resulting right- or left-sided paralysis (hemiplegia) are at risk for footdrop. Patients that are bedridden for extended periods of time are at risk. What is the nursing implication? The nursing implication is prevention using the devices that your institution has available.

FVE & FVD

a. Body weight Daily weights reflect fluid retention or loss. A 1-L amount of fluid weighs 2.2 lbs (1 kg). Compare with previous day's weight if available. Gain or loss of 2 lbs (1 kg) in 24 hours indicates gain or loss of 1 L of fluid. Body fat gain or loss takes longer.968 b. Clinical markers of vascular volume: Assess signs and symptoms as a group to interpret them accurately. Infusion of Na+-containing IV fluid expands extracellular fluid volume (ECV) (vascular and interstitial). (1) BP Decreased BP or orthostatic hypotension may indicate ECV deficit caused by decreased stroke volume. Increased BP may indicate ECV excess. (2) Pulse Baroreceptor response causes rapid, thready pulse with ECV deficit; bounding, full pulse with ECV excess. (3) Fullness of neck veins (normally neck veins are full when person is supine and flat when person is upright or semi-upright) Indicator of fluid volume status: flat or collapsing with inhalation when supine with ECV deficit; full or distended when upright or semi-upright with ECV excess. (4) Capillary refill Provides an indirect measure of tissue perfusion. Can indicate poor tissue perfusion (sluggish with ECV deficit). (5) Auscultation of lungs Crackles or rhonchi in dependent lobes of lung may signal fluid buildup in lungs caused by ECV excess. (6) Urine output (decreased; dark yellow with ECV deficit) Kidneys respond to ECV deficit by reducing urine production and concentrating the urine. Average daily adult urine output is 1500 mL; oliguria is urine output of less than 400 mL/24 hr. Kidney disease and syndrome of inappropriate antidiuretic hormone (SIADH) also can cause oliguria. Dark yellow indicates concentrated urine. c. Clinical markers of interstitial volume: Assess signs and symptoms as a group to interpret them accurately. Infusion of Na+-containing IV fluid expands ECV (vascular and interstitial). (1) Dependent edema (rate severity by assessing pitting over bony prominences (i.e., 1+ indicates barely detectable edema; 4+ indicates deep persistent pitting) (see Chapter 31). Edema, indicating expanded interstitial fluid volume, is most evident in dependent areas bilaterally (i.e., feet and ankles if sitting) or sacrum if bedfast. (2) Oral mucous membranes between cheek and gum More reliable indicator than dry lips or skin. Dry between cheek and gums indicates ECV deficit. (3) Skin turgor (pinch skin over sternum or inside of forearm) (Failure of skin to return to normal position within 3 seconds indicates ECV deficit.) Pinched skin that stays elevated for several seconds is called poor skin turgor or "tenting." May occur from ECV deficit, rapid weight loss, or normal aging. d. Thirst Occurs with hypernatremia and severe ECV deficit. Not a reliable indicator for older adults because thirst sensation decreases with age (Touhy and Jett, 2014). e. Behavior and level of consciousness (1) Restlessness and mild confusion Occurs with severe ECV deficit caused by lack of blood flow to brain. (2) Decreased level of consciousness (lethargy, confusion, coma) May occur with osmolality imbalances (hyponatremia and hypernatremia) and acid-base imbalances.

Duration of Pain

acute (transient) and chronic (persistent)

Gait

describes a particular manner or style of walking. It is a coordinated action that requires the integration of sensory function, muscle strength, proprioception, balance, and a properly functioning CNS (vestibular system and cerebellum). A gait cycle begins with the heel strike of one leg and continues to the heel strike of the other leg. Assessing a patient's gait allows you to draw conclusions about balance, posture, and the ability to walk without assistance, all of which affect the risk for falling. Here are a few ways to assess a patient's gait: 1. Observe the patient entering the room, and note speed, stride, and balance. 2. Ask the patient to walk across the room, turn, and come back. 3. Ask the patient to walk heel-to-toe in a straight line. This may be difficult for older patients even in the absence of disease, so stay at the patient's side during the walk

Possible Sources for Error in Pain Assessment

• Bias, which causes nurses to consistently overestimate or underestimate the pain that patients experience • Vague or unclear assessment questions, which lead to unreliable assessment data • Use of pain assessment tools that are not evidence based or validated in a particular patient population • Use of medical terms that patients with low health literacy cannot understand • Patients who do not always provide complete, relevant, and accurate pain information • Patients who are cognitively impaired and unable to use pain scales

Key Points Chapter 44

• Pain is a purely subjective physical and psychosocial experience. • Misconceptions about pain often result in doubt about the degree of the patient's suffering and unwillingness to provide relief. • Knowledge of the nociceptive pain processes of the pain experience (i.e., transmission, transduction, perception, and modulation) provides guidelines for selecting pain-relief measures. • A person's cultural background influences the meaning of pain and how it is expressed. • Older patients commonly underreport pain and believe that it is unacceptable to show or express pain. • Cancer pain is still not adequately treated, despite clinical guidelines for the effective use of opioids and other pharmacological alternatives. • The difference between acute and chronic pain involves the concept of harm. Acute pain is protective, thus preventing harm; chronic pain is no longer protective and does not provide any benefit. • Do not collect an in-depth pain history when the patient is experiencing severe discomfort. Wait until the pain is better controlled. • Pain often causes physical signs and symptoms similar to those of other diseases. • Individualize pain interventions by collaborating closely with patient, using assessment findings and trying a variety of interventions. • Eliminating sources of painful stimuli is a basic nursing measure for promoting comfort. • Prescribing analgesics on a prn basis for chronic pain is ineffective and causes more suffering; thus patients with chronic pain need to take analgesics ATC, even when their pain subsides. • Sedation is an adverse effect of opioids that always precedes respiratory depression. • A PCA device (without a basal infusion) gives patients pain control with lower risk of overdose. • While caring for a patient who receives local anesthesia, protect him or her from injury. • Nursing implications for administering epidural analgesia include preventing infection, assessing sensation and motor function, and monitoring closely for respiratory depression. • Addiction rarely occurs in patients who take opioids to relieve pain. • Breakthrough pain is a challenging aspect of cancer because it can impact the quality of life of patients and family caregivers; thus it requires a holistic approach to treatment. • Pain evaluation includes measuring the changing character of pain, the patient's response to interventions, and his or her perceptions of the effectiveness of a therapy.