Module 4 PP
transmission
- : A-delta and C fibres transmit the stimulus via thick myelinated and unmyelinated fibres respectively. A-delta fibres are sharp, stinging, and highly localized signals which travel quicker than C fibers to the CNS. C fibers transmit slowly and are poorly localized thereby producing a dull or aching quality. Most pain sensations travel via C fibers and project into the brain areas which evoke an emotional response. Signals transmit along the posterior nerve root synapsing with interneurons, anterior motor neuron, and sympathetic preganglionic neurons. Glutamate binds to a NMDA receptor inducing synaptic memory. Excessive or repeated stimulation of C fibers sensitizes the spinal cord neurons (drugs which inhibit glutamate may prevent this synaptic memory formation). Anterolateral (spinothalamic) tract is the ascending pathway. There are two divisions: the neospinothalamic tract and paleospinothalamic tract. (Both proceed in a contralateral function.) The neospinothalamic division has fewer synapses and projects first to the thalamus and then to the primary somatosensory cortex; A-delta fibers transmit along this tract and provide specific location information and little emotional connotation. C fibers travel along the paleospinothalamic division, which has greater number of synapses and reaches the brain more slowly; projects widespread into the brain and evokes a stronger emotional response. Pain fibers stimulate the brainstem, reticular formation, and the thalamus (which stimulates the cortex, basal ganglia, and limbic system). Lamina V is a key area in the spinal cord for referred pain. Key neurotransmitters and neuropeptides include Substance P, glutamate (excitatory amino acid), GABA, cholecystokinin, and calcitonin gene-related peptide. Interruption of these transmitters can inhibit pain transmission.
modulation
- : occurs in the peripheral and central nociceptors. Gate Theory posits that activation of certain cognition neurons inhibits nociceptors by interrupting the transmission of pain stimuli in the spinal cord; the substantia gelatinosa, which lies on the posterior tract, is a location where impulses can be enhanced or blocked. Presynaptic inhibition can be modulated through inhibition of Substance P and the effects of opioids like endorphins. Serotonin conveys analgesic signals from the midbrain to the brain stem. The brain modulates pain perception through its own opioid receptors (stress-induced analgesia).
perception
- : the primary somatosensory cortex, association cortex, frontal lobe, and limbic system are responsible for the localization, process, and interpretation of pain. Pain perception has a similar threshold person to person; pain tolerance varies by person as well as pain expression.
pain assessment - location
- Pain assessment begins by careful patient observation, noting overall posture and presence or absence of overt pain behaviours. - Important to ask patient to describe in their own words their pain as it may point to a cause - Location: have the patient point to the area of the body invovled best determines the location of pain - helpful when pain radiates to shade area where the pain is : helps with effectiveness or if the pain location changes
pain assessment - quality
- Quality (description): ask to describe pain in their own words without offering clues. If patient is unable to describe the quality they can suggest words like burning, aching, throbbing, or stabbing. It is important to document exact words used by the patient to describe the pain and which words the nurse suggested
pain assessment - quantity
- Quantity (intensity) : the intensity of pain ranges from none to mild discomfort to excruciating. There is no correlation between reported intensity and the stimulus that produced it. To understand variations the nurse can ask about the present pain intensity as well as the least and the worst pain intensity. Various scales and surveys are helpful to patients trying to describe pain intensity
Pain Assessment - timing
- Timing: sometimes the cause of the pain can be determined when time aspects are known. Therefore, the nurse inquires about the onset, duration, relationship between time and intensity, and change in rhythmic patterns. - Did the pain increase gradually, or come on suddenly? - Sudden pain tissue injury and immediate intervention is necessary - Pain from ischemia gradually increases and becomes intense over a long period of time. - The chronic pain of rheumatoid arthritis illustrates the usefulness of determining the relationship between time and intensity because people with RA usually report that pain is worse during the night - Clinicians consistently underestimate patients levels of pain. Therefore a number of pain assessment tools *if you would like to read up on them med surg p. 256
transduction
- translation of a noxious stimulus into a chemical signal which is then transmitted to the CNS. Important chemical mediators include potassium, hydrogen ions, lactate, histamine, serotonin, bradykinins, and prostaglandins. These chemicals sensitize nociceptors by reducing the action potential threshold. NSAIDS are effective drugs that interrupt the formation of prostaglandins by inhibiting cyclooxygenase. Prostaglandins are formed when cells are damaged by phospholipase A, which breaks down the phospholipids in the plasma membrane and then converts the molecules into arachidonic acid. Cyclooxygenase further catabolizes this acid to form prostaglandins.
angiogenesis antagonist anti platelet
Angiogenesis: is the physiological process through which new blood vessels form from pre-existing vessels Antagonist: A substance that acts against and blocks an action Antiplatelet: is a member of a class of pharmaceuticals that decrease platelet aggregation and inhibit thrombus formation
antipyretic bradykinin chemokine
Antipyretic: used to prevent or reduce fever. Bradykinin: is an inflammatory mediator. It is a peptide that causes blood vessels to dilate, and therefore causes blood pressure to fall Chemokines: any of a group of low-molecular weight cytokines. They function as regulators of the immune system that help immune cells localize to areas of injury
chemotaxis complement Cox 1 enzyme
Chemotaxis: the movement of cells according to chemical gradients (chemotaxins) that attract them Complement: a protein that participates in the cascade of reactions resulting in inflammation and cell lysis. Complement activation can occur by the classical or the alternative pathways Cox 1 enzyme: enzyme that acts to speed up the production of certain chemical messengers, called prostaglandins, in a variety of areas of the body such as the stomach, kidneys, and sites of inflammation
Cox 2 enzyme C reactive protein Cytokines
Cox 2 enzyme: enzyme that acts to speed up the production of certain chemical messengers, called prostaglandins that play a key role in in promoting inflammation. When cox-2 activity is blocked, inflammation is reduced. C-reactive protein: ** not in glossary: usually an inflammation marker Cytokines: a peptide factor released by cells to influence the behavior of target cells. They have signaling, inflammatory, growth, and inhibitory functions
epitheliazation fever fibroblasts histamine
Epithelialization: formation of granulated tissue post wound ESR: Fever: abnormally high body temperature Fibroblasts- a cell that synthesizes the extracellular matrix and collagen. Most common type of cells of connective tissue. Histamine- Compound released by cells in response to injury and allergic and inflammatory reactions. Causes contraction of smooth muscle and dilation of capillaries.
infection inflammation
Infection- the invasion of an organism's body tissues by disease-causing agents, and the reaction of host tissues to the infectious agents and the toxins they produce. Inflammation-localized physical condition in which part of the body becomes reddened, swollen, hot, and painful. Response to harmful stimuli (pathogens, damaged cells, or irritants). Protective response involving immune cells, blood vessels, molecular mediators.
kinins leukotriene maceration
Kinins-Inflammatory mediators that cause dilation of blood vessels and altered vascular permeability. Small peptides produced from kininogen. Leukotriene: a class of biologically active compounds produced by leukocytes that trigger allergic and inflammatory reactions similar to those of histamine Maceration: softening of breaking down of skin resulting from prolonged exposure to moisture
7. What are common concerns and misconceptions about pain and analgesia?
Neonates were thought to lack a fully formed CNS and therefore did not require analgesics for surgical procedures. It has since been found that inadequate analgesics may lead to persistent behavioural changes and physical changes in the CNS. Sensation of pain in the elderly is assumed to decrease or be a natural part of aging. Studies have been inconclusive to this point. Even cognitively impaired adults may still perceive pain although unable to communicate needs.
neuralgia neuropathy
Neuralgia: intense, typically intermittent pain along the course of a nerve, especially in the head or face Neuropathy: tissue injury in which the nerves themselves become damaged or dysfunctional. May occur in the peripheral or central nerves
nociceptive
Nociceptive: detect pain. activation of sensory transduction in nerves by thermal, mechanical, or chemical energy impinging on specialized nerve endings; the nerves involved convey information about tissue damage to the central nervous system
opiod
Opioid: a morphine-like compound that produces bodily effects including pain relief, sedation, constipation, and respiratory depression
phagocytosis prostaglandin
Phagocytosis: ingestion of pathogens by leukocytes using the process of receptor-mediated endocytosis. Prostaglandin: unsaturated fatty acids that have a wide assortment of biologic activity
referred pain somatic
Referred (pain): perceived as coming from an area that in which the pathology is occuring Somatic: relating to the body
thromboxane visceral
Thromboxane: (A2) substance liberated from platelets that aggregate at the site of damaged vessels causing arteriolar vasoconstriction and continued platelet aggregation Visceral: referring to the internal organs of the body.
arterial ulcers
a. Arterial Ulcers- Also caused ischemic ulcers. Caused by inadequate blood flow to lower extremities. Have a punched-out appearance that is deeper and smaller than venous ulcers. Located on feet, tips of toes, on toe joints and other locations on lower leg. Can be necrotic and black in appearance or have very pale wound beds. Legs are shiny, taut, hairless skin with translucent appearance. Resistant to healing- instead main goal is to provide comfort and prevent infection. Not good candidates for debridement because poor blood flow limits the ability to heal.
What are delegation considerations for care of wounds?
a. Assessing risk for pressure ulcers cannot be delegated to unregulated care providers. b. Treating pressure ulcers cannot be delegated to UCPs c. Applying dressing cannot be delegated to UCPs d. Wound irrigation cannot be delegated to UCPs e. Applying abdominal/breast binders and elastic bandages can be delegated to UCPs i. UCPs should immediately report changes in patient's respiratory status, increase in wound drainage, changes in skin integrity under/adjacent to the binder, increase in patient pain, remove the binder at prescribed intervals.
10. What are benefits, actions, and adverse effects with the use of opioids?
a. Benefits: acute or chronic pain analgesic and CNS depression. b. Actions: mu. Kappa, sigma, delta, and epsilon agonists which stimulate numbness and stupor-like states. c. Adverse effects: dysphoria, hallucinations, nausea, constipation, dizziness, and pruritis.
. What are the benefits, actions, and adverse effects of NSAIDS (non-steroidal anti-inflammatory drugs)? Med surg. P 265
a. Benefits: reduces moderate pain and inflammation, helpful in treating arthritic diseases and may be especially powerful in treating cancer related bone pain b. Actions: inhibits cyclooxygenase which inhibits prostaglandin production from traumatized or inflamed tissues. c. Adverse effects: gastric discomfort and increased risk of bleeding.
diabetic ulcers
a. Diabetic Ulcers- Occur because of neuropathic changes related to diabetes. Found over bony prominences on plantar surface of foot, over metatarsal heads, beneath the heels. Changes include sensory neuropathy, loss of protective sensation (can't feel pain or temp changes), autonomic neuropathy, absence of sweating leading to dry skin with fissures, cracks, calluses over pressure points, motor neuropathy (resulting in changes in muscle contractions leading to high arches and hammer toes)
What is the relationship of ischemia to pressure ulcers and arterial ulcers?
a. If a patient has ischemia, there is less blood flow to an area of tissue and oxygen and nutrients cannot reach the cells and wastes cannot be removed, so the cells in the tissue will begin to die.
4. What are the phases of wound healing and list the physiological process occurring in each?
a. Inflammation- blood vessels in the wound contract and the injured tissue releases collagen which promotes platelet aggregation, thus forming a clot. Once hemostasis has occurred, the blood vessels dilate to allow antibodies, WBCs (phagocytes, neutrophils, macrophages), growth factors, enzymes, and nutrients to flow into the wound tissue. Characteristics of inflammation include erythema (superficial reddening of the skin), warmth, edema, pain, and functional disturbance. b. Proliferation- the wound is rebuilt with granulation tissue made from collagen and extracellular matrix. Angiogenesis occurs (formation of new blood vessels). Granulation tissue formation is depended on the fibroblasts receiving adequate oxygen and nutrients. Granulation tissue is granular, uneven, does not bleed easily, pink/red. The condition of the granulation tissue is an indicator of how well the tissue is healing (dark tissue= poor perfusion, ischemia, infection). Epithelialization occurs, where epithelial cells resurface the wound, moving from the edges of the wound inwards. c. Maturation- This phase occurs once the wound has closed. Remodelling of collagen occurs. Cellular activity slows and the number of blood vessels decreases.
. What are non-pharmacological strategies to manage pain? Med surg. P. 274
a. Massage b. Thermal therapies c. Distraction d. Relaxation techniques e. Guided imagery f. Hypnosis g. Music therapy h. Transcutaneous electrical nerve stimulation (TENS)
venous ulcers
a. Venous Ulcers-Caused by weak vein in the legs and decreased ROM decreases the ability of the calf muscles to pump (decreases venous return). Serum and RBCs leak into the surrounding tissue, which causes brownish hemosiderin staining of the tissue. Superficial and irregular in shape. Large amount of exudate caused by edema in surrounding tissue. If chronic, the edema in the tissue becomes firm and the lower legs develop a wooden-like appearance (lipodermatosclerosis).
WOUND pneumonic
a. What happened- cause of wound, how long it has been around. b. Oxygen- factors impeding circulation, smoking, respiratory disease, oxygen therapy, pain, temperature, signs of infection. c. Underlying factors- age, lifestyle, stress, sleep. d. Nutrition- diet, fluid balance, IV therapy. e. Disease- relevant history of disease, surgeries, comorbidities.
example of over reaction of inflammatory system
allergy
. What are is the rationale for using various pharmacological options to manage inflammation, fever and allergies and what is the related nursing process? (antihistamines, NSAIDS, glucocorticoids, antipyretics)
antipyretics glucocorticoids NSAIDS Antihistamines
Inflammatory bowel disease (IBD)
churns disease and ulcerative colitis
hypoxemia
deficient amount of oxygen in the blood
what diagnostic test relates to inflammation
erythrocyte sedimentation rate
a. Anti-seizure medications
i. Benefits: reduced neurological pain ii. Actions: enhances the effect of GABA which suppresses abnormal neuronal discharges which desensitizes nociceptor threshold. iii. Adverse effects: drug dependency, drowsiness, vitamin deficiencies (vitamin D, folate, and vitamin B12), and laryngospasm; respiratory depression, CNS depression, coma, and death.
a. Tricyclic antidepressants med surg - 266
i. Benefits: reduced neurological pain ii. Actions: inhibits reuptake of serotonin and epinephrine at synaptic terminals, which stimulate endorphin release in the brain thereby reducing pain perception. iii. Adverse effects: sedation, drowsiness, blurred vision, dry mouth, dysrhythmias, heart block, and hypertension; increased risk of serotonin and norepinephrine toxicity.
phagocytosis
neutrophils and monocytes start phagocytosis especially of the extracellular matrix. These cells produce a wide variety of enzymes to digest protein structures. Some of these include lysozymes, neutral protease, collagenase, elastase and acid hydrolase. Oxidizing agents are the most productive at destructing inflammation. Inflammatory inhibitors (antiprotease) which is made in the liver to circulate the blood stream. Neutrophils leave infection and die immediately and can no longer return and pus forms may form and macrophages will then clear the cite for healing
How does cellular healing take place? What occurs during regeneration and during replacement?
reconstructive regeneration maturation
ulcerative colitis
■ A recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum ■ Characterized by multiple ulcerations, diffuse inflammations, and desquamation or shredding of the colonic epithelium ● Bleeding occurs as a result of the ulcerations ● The mucosa becomes edematous and inflamed ■ The lesions are contiguous, occuring one right after the other ■ Disease process begins in the rectum, and spreads proximally to involve the entire colon ■ Eventually the bowel narrows, shortens, and thickens because of muscular hypertrophy and fat deposits ■ Clinical manifestations ● Diarrhea, passage of mucus and pus, left lower quadrant abdominal pain, intermittent tenesmus, and rectal bleeding ○ Bleeding may be mild or severe, and pallor, anemia, and fatigue result ● Patient may have anorexia, weight loss, fever, vomiting, and dehydration, as well as cramping, the feeling of an urgent need to defecate, and the passage of 10-20 liquid stool each day ● Hypocalcemia and anemia frequently develop ● Rebound tenderness may develop in the lower quadrant
regeneration
■ Requires survival of the basement membrane and tissue stem cells ■ Some cell types regenerate constantly; among these types are the epithelial cells of the skin and mucous membrane, bone marrow cells, and lymphoid cells ■ Cells of the liver, pancreas, endocrine glands, and renal tubules are also able to regenerate when necessary ■ Neurons and muscles cells regenerate poorly
Chron's disease
■ Subacute and chronic inflammation of the GI tract wall that extends through all layers ■ Occurs commonly in the distal ileum and, to a lesser degree, the ascending colon ■ Disease process begins with edema and thickening of the mucosa ■ As the disease advances, the bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows ■ Diseased bowel loops sometimes adhere to other loops surrounding them ■ Clinical manifestations ● Prominent right lower quadrant abdominal pain and diarrhea unrelieved by defecation ● Scar tissue and the formation of granulations interfere with the ability of the intestine to transport products of upper intestinal digestion through the constricted lumen, resulting in crampy abdominal pains ● Abdominal tenderness and spasms ● Pain occurs after meals ● Weight loss, malnutrition, and secondary anemia may occur ● Ulcers in the membranous lining of the intestine and other inflammatory changes result in a weeping, edematous intestine that continually empties an irritating discharge into the colon ● Disrupted absorption causes chronic diarrhea and nutritional deficits ○ The result is a person who is thin and emaciated from inadequate food intake and constant fluid loss ● In some patients, the inflamed tissue may perforate, leading to intra abdominal and anal abscesses ● Fever and leukocytosis may occur ● Chronic symptoms ○ Diarrhea ○ Abdominal pain ○ Steatorrhea (excessive fat in the feces), anorexia, weight loss, and nutritional deficiencies
nociception
■ Transduction ● The process of converting painful stimuli to neurological action potentials at the sensory receptor ■ Transmission ● The movement of action potentials along neurons to make their way from the peripheral receptor to the spinal cord and then centrally to the brain ■ Perception ● When the brain receives pain signals and interprets them as painful ■ Modulation ● The complex mechanism whereby synaptic transmission of pain signals is altered
reconstructive phase
■ begins 3-4 days after injury and persists for 2 weeks ■ Major cells involved in this phase include fibroblasts, endothelial cells, and myofibroblasts ■ Fibroblasts ● Found all over the body ● Thought to originate from in mesenchymal primitive tissue ● Synthesize connective tissue and are able to migrate ● Stimulated to make collagen, proteoglycans, and fibronectin by a variety of growth factors ● Macrophages secrete lactate and release growth factors that stimulate fibroblasts ● Fibroblasts respond to contact and density inhibition and thereby facilitate orderly cellular growth ■ Myofibroblasts ● Develop at the wound edge and induce wound contraction ■ Endothelial cells ● Grow into the connective tissue gel stimulated by angiogenic substances ● They usually develop capillary beds from existing vessels. New capillaries can transport nutrients for tissue repair and wound healing. However, because the new capillaries are leaky, they contribute to continuing edema
Other pain relief methods
○ A subcutaneous system is used for difficult to control pain. A silicone catheter is inserted to the affected area and local anesthetic is administered to the site. ○ Non Pharmacological pain relief measures include guided imagery, music and application in pain or heat. ○ Repositioning, using distraction and applying cool washcloths to the face or providing a back massage has been shown to relieve discomfort.
acute pain
○ Acute pain results from tissue injury and resolves when the injury heals, usually in less than 3 months (med surg says 6 months) ○ Usually accompanied by clinical signs and symptoms of pain that result from stimulation of the SNS ■ Elevated heart rate ■ Elevated respiratory rate ■ Elevated blood pressure ■ Pallor ■ Sweating ■ Nausea ○ People experiencing acute pain express pain behaviour such as: ■ Pacing ■ Grimacing ■ Crying ■ Moaning ○ Short term therapy with non opioids and opioid agents is often helpful
opiod analgesics
○ Administered for pain prevention rather than "as needed" for post-operative patients ○ Little risk for drug addiction if it is a short term use
rheumatoid arthritis
○ Autoimmune disease of unknown origin ○ Primarily occurs in the synovial tissue ○ Phagocytosis produces enzymes within the joint and the enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation ■ Pannus destroys cartilage and erodes the bone ■ The consequence is loss of articular surface and joint motion ○ Muscle fibres undergo degenerative changes ○ Tendon and ligament elasticity and contractile power are lost ○ Clinical manifestations ■ Clinical manifestations of RA vary and usually reflect the stage and severity of the disease ■ Joint pain, swelling, warmth, erythema, and lack of function are classic symptoms ■ Limitation of function can occur when there is active inflammation in the joints ● Joints that are hot, swollen, and painful are not easily moved ■ RA is a systemic disease with multiple extra-articular features ● Fever, weight loss, fatigue, anemia, lymph node enlargement, and raynaud's phenomenon
procedural pain
○ Brief, intense pain that arises from diagnostic, therapeutic, and preventative procedures ○ Lasts from seconds to hours ○ If significant tissue damage occurs, procedural pain could become acute pain
NSAIDS
○ COX-2 inhibitors cause less GI distress but have more cardiovascular risks and side effects as they are over the counter, this includes ASA and ibuprofen. ○ They inhibit analgesic and antipyretic and antipyretic actions. ○ They inhibit prostaglandins and inhibits inflammation by blocking cyclooxygenase. ○ They have the effect to damage the digestive system by making more gastric acid secretion and irritating the stomach lining. ○ It may produce epigastric pain, heartburn, and bleeding due to ulceration. ○ High doses may produce salicylism syndrome (includes tinnitus, dizziness, headache and sweating). ○ Nurses involves monitoring and educating. ○ People should be monitored for bleeding disorders, peptic ulcers, anticoagulants, alcoholism, CHF, fluid retention, which may exacerbate hypertension and renal diseases. ○ These should not be given to patients with liver problems. ○ Obtain baseline kidney function, liver function and a CBC. ○ During medication assess for pain changes, reduction In temperature and inflammation, GI bleeds, hepatitis, nephrotoxicity, hemolytic anemia and salicylate toxicity. ○ Other common side effects may include tinnitus, abdominal cramping and heartburn. ○ The following are NSAIDS teaching points: ■ do not give them to children ■ take Nsaid with food or milk to decrease gastric upset ■ read labels of OTC drugs ■ avoid alcohol ■ consult a health care provider taking herbal products ■ effects may not occur for 1-3 weeks ■ report immediate sign of bleeding stool, increased bruising, headache or dizziness
glucocorticoids
○ Can suppress severe cases of inflammation. ○ Natural hormones ○ These are used for severe cases of inflammation. ○ These are natural hormones released by the adrenal cortex. ○ These are used to treat neoplasia, asthma, arthritis and corticosteroid deficiencies. ○ They suppress histamines and inhibit prostaglandin COX-2. ○ In addition they inhibit the immune system by suppressing phagocytes and lymphocytes. ○ These are the best thing to help with inflammatory disorders. ○ They do have serious adverse effects. They suppress the adrenal gland, hypoglycemia, mood changes, cataracts, peptide ulcers, electrolyte imbalances and osteoporosis. ○ They reduce signs and symptoms of inflammation, glucocorticoids can also mask infections. ○ These medications are only used every other day to allow functioning of the adrenal gland before getting cushing syndrome. ○ Nurses should monitor the patient's condition and educate them. ○ Nurses should first screen the patient for an infection. ○ They should be used with great caution in patients with HIV and TB. ○ The metabolic status, fluid, electrolytes, body weight, CBC, serum, glucose, sodium and potassium levels, and should be monitored for greater exhausturbation because glucocorticoids promote RBC proliferation. ○ Osteoblasts formation is also suppressed, so caution should be used with patients with osteoporosis. ○ Diabetics also may be careful because this drug also raises BG. ○ The client should be monitored for cushing syndrome, signs include bruising, fat deposit in cheeks, shoulders and abdomen. ○ It may alter mucus lining of stomach oral doses should be should be given with food to prevent this. ○ Clients with peptic ulcer disease shouldn't receive this. ○ It should be injected deep into the muscles to avoid atrophy. ○ Teaching points include: ■ Take the meds at the same time each day ■ never abruptly stop taking the medication ■ take with food to avoid gastric irritation ■ guard against infection ■ weigh yourself daily, check ankles and legs from swelling because they can cause fluid retention ■ immediately report difficulty breathing, heart burn, abdominal/chest pain, nosebleed, blood cough, vomit, urine, or stool, fever, chills, fruity breath, signs of infection, falls, mood swings
What are common respiratory issues post-operative patients are at risk for? What interventions does the nurse do to prevent respiratory complications?
○ Decreased lung expansion secondary to pain and decreased mobility put the patient at risk for atelectasis (alveolar collapse; incomplete expansion of the lung), pneumonia and hypoxemia. ○ Atelectasis: ambulate patient, perform deep breathing and coughing exercises using an incentive spirometer. ○ Signs and symptoms of atelectasis: decreased breath sounds over affected areas, crackles and cough. ○ Pneumonia: ambulate patient to prevent fluid build up at the bases of the lung, occurs frequently with older patients. ■ Hypostatic pneumonia caused by a weakened immune system that permits stagnation of secretions at lung bases ○ Signs and symptoms of pneumonia: fevers and chills, tachycardia and tachypnea. ○ Hypoxemia: two types - subacute & episodic (monitor SpO2) Subacute hypoxemia: is a constant low level of oxygen saturation when breathing appears normal Episodic hypoxemia: develops suddenly and the patient may be at risk for cerebral dysfunction, myocardial ischemia and cardiac arrest.
PCAs
○ Goal is pain prevention rather than pain control as patients recover more quickly ○ Two requirements of PCA: understanding the need to self-dose and the physical ability to self-dose is needed for patients who are on PCA's. ○ Administered IV route or epidermal route ○ PCA's enable patients to control their timing of their dose and allow them to stay in their therapeutic range ○ Patients are able to move, turn, cough and take deep breaths with less pain, thus reducing their risk for pulmonary complications
IBD - reduce symptoms
○ Maintaining normal elimination patterns ○ Relieving pain ○ Maintaining fluid intake ○ Maintaining optimal nutrition ○ Promoting rest ○ Reducing anxiety ○ Enhancing coping measures ○ Preventing skin breakdown ○ Monitoring and managing potential complications ○ Promoting home and community-based care
osteoarthritis
○ OA affects the articular cartilage, subchondral bone, and synovium ○ A combination of cartilage degradation, bone stiffening, and reactive inflammation of the synovium occurs ○ Usually due to increasing age and the degenerative process in the joint, because of the ability of the articular cartilage to resist microfracture with repetitive low loads diminishes with age ○ Clinical manifestations ■ Pain, stiffness, and functional impairment ■ Pain is caused by an inflamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes (bone spurs), trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm
cancer related pain
○ Pain associated with cancer may be acute or chronic ○ May be directly associated with the cancer (bony infiltration with tumour cells and nerve compression), a result of cancer treatment (surgery or radiation), or not associated with cancer ○ Most pain is associated with direct tumour involvement
harmful effects - procedural pain
○ Poorly managed procedural pain has adverse and often long-lasting physiologic and psychological effects ○ Can give rise to a cycle of pain, anxiety, and fear that ultimately may lead to avoidance of the procedure ○ People will often avoid medical or dental care out of fear of the procedures
secondary intention
○ Second intention healing (granulation) occurs in infection wounds (abscess) or in wounds in which the edges have not been approximated ○ When an abscess is incised, it collapses partly, but the dead and dying cells forming its walls are still being released into the cavity ○ For this reason, a drainage tube or gauze lacking is inserted into the abscess pocket to allow drainage to escape easily ○ gradually , the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily ○ This tissue is composed of minute, thin-walled capillaries tand buds that later form connective tissue ○ These buds, called granulations, enlarge until they dill the area left by the destroyed tissue ○ The cells surrounding the capillaries change their round shape to become long, thin, intertwined to form a scar (cicatrix) ○ Healing is complete when skin cells (epithelium) grow over these franualtons ○ This method of repair is called healing by granulation, and it take place whenever pus is formed or when loss of tissue has occurred for any reason ○ When the postoperative wound is to be allowed to heal by secondary-intention, it is usually packed with saline-moistened sterile dressings and covered with a dry sterile dressing
harmful effects of pain - chronic
○ Suppression of the immune function associated with chronic pain may promote tumour growth ○ Often results in depression and disability ○ Failure to administer adequate pain relief may be unsafe ○ Results in poor quality of life ○ Those most affected by chronic pain are more likely to be unemployed or underemployed and have lower incomes compared with those who do not have pain
tertiary intention
○ Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two opposing granulation surfaces ○ This results in a deeper and wider scar ○ These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing
harmful effects of pain - acute
○ Unrelieved acute pain can affect the pulmonary, cardiovascular, gastrointestinal, endocrine, and immune systems ○ The widespread endocrine, immunologic, and inflammatory changes that occur with the stress response can have significant negative effects ■ Specifically harmful in patients who are already compromised by age, illness, or injury ○ Stress response ■ Increases metabolic rate ■ Cardiac output ■ Impaired insulin response ■ Increased production of cortisol ■ Increased retention of fluids ■ May increase risk of physiological disorders (MI, pulmonary infection, etc.) ○ Patients with severe pain may not be able to take deep breaths and may experience increased fatigue and decreased mobility
● Epidural Infusions and Intrapleural Anesthesia
○ Used with caution in chest procedures because the analgesic may ascend along spinal cord and affect respiration ○ Intrapleural anesthesia involves the administration of local anesthetic by a catheter between the parietal and visceral pleura. ○ Provides sensory anesthesia without impacting motor function to the intercostal muscles ○ Allows more effective coughing and deep breathing in conditions such as cholecystectomy, renal surgery and rib fractures.
arthritis - reduce symptoms
○ Weight loss and exercise ○ Canes or assistive devices ○ NSAIDs ○ Application of heat or cold ○ Massage ○ Foam mattresses, supportive pillow, splints ○ Relaxation techniques ○ Anti-inflammatory meds, analgesics ○ Encourage verbalization of feelings about pain and chronicity of disease ○ Teach pathophysiology of disease to increase patient understanding ○ Identify environmental barriers ○ Educate about adequate nutritional diet
chronic pain
○ When it lasts more than several months beyond expected healing time ○ Can seldom be attributed to a specific cause or injury ○ Poorly defined onset ○ May be a patient's primary disorder ○ Unrelieved chronic pain is associated with socioeconomic burdens ○ Three main categories of causes of chronic pain
primary intention
○ Wounds made aseptically with a minimum of tissue destruction that are properly closed heal with little tissue reaction by first intention (primary union) ○ When wounds heal by first-intention healing, granulation tissue is not visible and scar formation is minimal ○ Postoperatively, many of these wounds are covered with a dry sterile dressing ○ If a cyanoacrylate tissue adhesive (liquiband) was used to close the incision without sutures, a dressing is contraindicated
antihistamines
○ is to block the action of histamine at the H1 receptor. ○ H1 receptor antagonist is a more effective name this are used to treat the reaction from an allergy. ○ They are widley used OTC for relief of allergy symptoms, motion sickness, and insomnia ○ The nurses role is to educate the patient on the drug and monitor their condition. ○ Before admin (of first generations antihistamines) they should monitor vitals and do an electrocardiogram in clients with heart disease history, they are contradict to the patients with HF, seizures, depression and glaucoma. ○ Elderly should be monitored for dizziness. ○ This could also be carefully monitored during pregnancy and discontinued during breastfeeding as it could enter breast milk. ○ Second generation same as above prior but don't affect depression patients, in addition are bad for patients with asthma or nicotine use, liver or kidney problems
antipyretics
○ is used for treatment of fevers and can be managed with OTC drugs, ASA, ibuprofen and acetaminophen. ○ Tylenol is the best ○ Many of these drugs are marked for different age groups. ○ ASA used to be the most common thing for children but can cause reye's syndrome. ○ Nursing considerations include education and monitoring. ○ Obtain clients vitals, assess developmental status. ○ Determine the appropriate route. ○ Kidney and liver status should be assessed because in damaged organs it may be toxic. ○ This is contraindicated in clients will liver disease, viral hepatitis, cirrhosis and alcoholism. Can greatly increase hepatotoxicity. ○ This also inhibits warfarin and may produce toxic accumulation. ○ Liver failure can be caused by overdose.
What are nurse/client collaborative measures and nursing strategies that should be implemented to optimize timely wound healing?
● Age of patient (older patients have less resilient tissue) ○ Handle all tissue gently ● Handling of tissues ○ Handle tissues carefully and evenly ● Hemorrhage ○ Monitor vital sign ○ Observe incision site for evidence of bleeding and infection ● Hypovolemia ○ Monitor volume deficit (circulatory impairment) ○ Correct by fluid replacement as prescribed ● Local Factors ○ Edema: elevate part; apply cool compresses ○ Inadequate dressing technique (too tight or small): follow guidelines for proper dressing technique ● Nutritional Deficits ○ Correct deficits; this may require parenteral nutritional therapy ● Foreign bodies ○ Keep wounds free of dressing threads and talcum powder from gloves ● Oxygen deficit (tissue oxygenation insufficient) ○ Encourage deep breathing, turning, controlled coughing ● Drainage accumulation ○ Monitor closed drainage systems for proper functioning ○ Institute measure to remove accumulated secretions ● Medications ○ Be aware of action and effect of medication patient is receiving ■ Corticosteroids mask presence of infection ■ Anticoagulants may cause hemorrhage ■ Broad-spectrum and specific antibiotics ineffective when wound is closed because of intravascular coagulation ● Patient overactivity ○ Use measure to key wound edges approximated: taping, bandaging, splings ○ Encourage rest ● Systemic disorders (hemorrhagic shock, acidosis, hypoxia, renal failure, hepatic disease, sepsis) ○ Be familiar with the nature of the specific disorder ○ Administer prescribed treatment ○ Cultures may be indicated to determine appropriate antibiotic ● Immunosuppressed states ○ Provide maximum protection to prevent infection ○ Restrict visitors with colds; institute mandatory hand hygiene by all staff ● Wound stressors (vomiting, valsalva maneuver, heavy coughing, straining) ○ Encourage frequent turning and ambulation and administer antiemetic medications as prescribed ○ Assist patient in splinting incision
nociceptive chronic
● Arises from constant stimulation of pain receptors and signals tissue damage in the skin, bone, joints, or viscera, has an aching or throbbing quality to it ● Arthritis is a good example
What are immediate post-operative assessments that the nurse does with a patient returning from surgery? What is the rationale for these assessments?
● Assess breathing and administer supplemental oxygen, if prescribed ○ Assessment provides a baseline and helps identify signs and symptoms of respiratory distress early ● Monitor vital signs and not skin warmth, moisture, and colour ○ A careful baseline assessment helps identify signs and symptoms of shock early ● Assess the surgical site and wound drainage systems. Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems ○ Assessment provides a baseline and helps identify signs and symptoms of hemorrhage early ● Assess level of consciousness, orientation and ability to move extremities ○ These parameters provide a baseline and help identify signs and symptoms of neurologic complication ● Assess pain level, pain characteristics (location, quality) and timing, type and route of administration of last dose of analgesic ○ Assessment provides a baseline of current pain level and for assessment of effectiveness of pain management strategies ● Administer analgesics as prescribed and assess their effectiveness in relieving pain ○ Administration of analgesics helps decrease pain ● Place the call light, emesis basic, ice chips (if allows), and bedpan or urinal within reach ○ Attending to these needs provides for comfort and safety ● Position the patient to enhance comfort, safety, and lung expansion ○ This promotes safety and reduces risk of postoperative complications ● Assess IV sites for patency and infusions for correct rate and solution ○ Assessing IV sites and infusions helps detect phlebitis and prevents errors in rate and solution type ● Assess urine output in closed drainage system or the patient's urge to void and bladder distention ○ Assessment provides a baseline and helps identify signs of urinary retention ● Reinforce the need to begin deep breathing and leg exercises ○ Prevent complications ● Provide information to the patient and family ○ Patient teaching helps to decrease the patient's and family's anxiety
What are nursing interventions around promoting cardiac output for this patient population?
● Assessing the patency of IV lines and ensuring correct fluids are administered at the prescribed rate ● Intake and output including emesis and output from wound drainage system are recorded separately to determine fluid balance ● If the patient's indwelling catheter outputs rates are less than 30mL/hr or if patient is voiding less than 240 mL/8 hour shift then monitor electrolyte levels and hemoglobin, and hematocrit. ● Encourage sips of water to promote fluid intake ● Patients are at risk for DVT, so leg exercises and frequent position changes are initiated early to stimulate circulation ● Promote venous return by anti embolism stocking and early ambulation.
Dehiscence vs Evisceration
● Dehiscence is the partial or total separation of wound layers ○ Prevention strategy is to provide support to the area, using a folded thin blanket or pillow places over an abdominal wound when the patient is coughing ○ Abdominal binder can provide support and prevent dehiscence ● Evisceration is the protrusion of visceral organs through the wound opening created by total separation of wound layers ○ When it occurs, you need to quickly place sterile towels soaked in sterile saline over the extruding tissues to reduce the chance of bacterial invasion and drying of the tissues and contact the physician ○ Do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery
What are nursing considerations for encouraging ambulation for the post-operative patient?
● Early ambulation for postoperative patients has a significant effect on recovery as prevents stasis of blood and thromboembolic events occur less frequently. ● Pain is often decreased when early ambulation is encouraged ● Remind patients the importance of ambulating early to encourage patients who are reluctant to move. ● The nurse must be aware of orthostatic hypotension when the patient gets out of bed for the first time. ● Assess patient's blood pressure in the supine position and when they get up again. ● Remain at the patient's side and encourage them to do as much as they can. ● If the patient is unable to ambulate then consider doing bed exercises such as arm exercises, hand and finger exercises and foot exercises, etc.
6. What are common gastrointestinal and genitourinary issues that the patient may experience? What are nursing interventions for them?
● GI issues: discomfort in the GI tract leading to nausea, vomiting and hiccups. ● Nursing Interventions ○ Vomiting/nausea: A nasogastric tube is inserted if the patient's risk of vomiting is high due to surgery. ○ Hiccups: Nothiazine medication may be prescribed by the physician if hiccups are a problem. ○ The nurse will assess the abdomen and auscultate for bowel sounds to assess the patient until normal GI functions return. ● GU issues: constipation due to decreased mobility, decrease oral intake and opioid analgesics. Urinary retention can occur due to anesthetics, anticholinergic agents and opioids interfere with the bladders fullness and the urge to void and inhibit the activity to initiate voiding and completely empty the bladder. ● Nursing Interventions ○ Constipation: Early ambulation, improved dietary intake and a stool softener to promote a bowel movement. ○ A laxative may be administered if the patient does not have a bowel movement after the 2nd or 3rd postoperative day. ○ Voiding: Assess bladder distention and urge to urinate post surgery. Expect patient to void within 8 hours after surgery ○ Encourage patient to void by letting water run, apply heat to the perineum. ○ If a patient is unable to void then the use of a straight intermittent catheter is needed. ○ Assess patient's residual volume prior to catheterization with a bladder scanner.
1. What is the role of histamine, cytokines and kinins in inflammation?
● Histamine is a key chemical mediator of inflammation. It is primarily stored within the Mast cells. Mast cells detect foreign agents or injury and response by releasing histamine, which initiates the inflammatory response within seconds. When released at an injury site, histamine dilates nearby blood vessels, causing capillaries to become more permeable. Plasma and components such as complement proteins and phagocytes can then enter the area to neutralize foreign agents. ● Cytokines are polypeptide signaling molecules that affect the function of other cells by stimulating surface receptors. They function in a complex intercellular communication network. They function to enhance and coordinate both innate and specific immune responses. ● Kinins are small polypeptides that cause powerful vasodilation. The system is linked to the clotting system and is activated with the activation of clotting.
sequence of events in the inflammatory process
● Increased Vascular Permeability ● Emigration of Leukocytes ● Phagocytosis ● pg . 172-174 patho
What are considerations around pain management for a post-operative patient?
● Intense pain stimulates the stress response which adversely affects the cardiac and immune systems. Transmitted pain impulses further stimulate both muscle tension and local vasoconstriction, further stimulating pain receptors. The hypothalamic stress response results in increased blood viscosity and platelet aggregation increasing the risk for thrombosis and PE.
maturation
● Occurs several weeks after the injury and may last for 2 years or more ● Characterized by wound remodeling by fibroblasts, macrophages, neutrophils, and eosinophils ● Wound remodeling is the process of collagen deposition and lysis with debridement of the wound edges ○ During this phase the wound changes color from bright red to pink to whitish ○ As long as the wound is pink, the maturation phase is not complete
What are ongoing potential issues that may arise and what is the role of the nurse? Pg. 501 MedSurg
● Respiratory: atelectasis, pneumonia, PE, aspiration ● Cardiovascular: shock, thrombophlebitis ● Neurological: delirium, stroke ● Skin/Wound: breakdown, infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma ● Gastrointestinal: constipation, paralytic ileus, bowel obstruction ● Urinary: Acute urine retention, urinary tract infection ● Functional: Weakness, fatigue, functional decline ● Thromboembolic: DVT, PE Assess the patient and reduce risks for each one of the issues accordingly.
mixed chronic
● Some chronic pain syndromes are both nociceptive and neuropathic ● Migraine is a good example
Nursing Interventions
● Time recognition of signs and symptoms help avert pulmonary complications ● Crackles indicate static pulmonary secretions that need to be mobilized by coughing and deep breathing exercises ● To clear secretions and prevent pneumonia; encourage patient to turn frequently, take deep breaths, cough and use incentive spirometer every hour ● Analgesic agents are administered to permit more effective coughing and oxygen is administered to prevent or relieve hypoxia ● Yawning or taking a sustained maximal inspiration is encouraged to create a negative intrathoracic pressure to expand lung volume.
neuropathic chronic
● Triggered by nerve damage or malfunction of peripheral and central nervous systems resulting in abnormal signalling ● The problem may begin with an injury or may be due to nerve compression by tumours, nerve inflammation by infection, or nerve impairment form systemic diseases such as diabetes ● Often has a burning, tingling, or piercing quality ● Allodynia, which is pain arising from a non painful stimulus such as a light breeze or light touch of clothing or bedding is also a characteristic of neuropathic pain ● Examples; neuralgia, diabetic neuropathy, and phantom limb pain sensation
venous, arterial, diabetic ulcers
● Venous: ○ Superficial and irregular ○ Usually a large amount of exudate caused by edema in the surrounding tissue ○ Venous insufficiency is related to weak vein walls in the legs; furthermore, limited range of motion in the ankle decreases the ability of the calf muscle to pump ○ Serum and RBCs leak into the surrounding tissue, which causes the characteristics brownish hemosiderin staining of tissue and skin ○ When chronic, edema in the tissue becomes firm and the lower legs develop wooden-like appearance ● Arterial ○ Caused by inadequate blood flow to the lower extremity (venous caused by poor blood return) ○ Have punched out appearance ○ Deeper and smaller than venous ○ Often on feet, tips of toes, or on the toe joints, but also on the rest of the lower legs ○ May be necrotic (black and crusted) or have very pale wound beds ○ Legs are thin and have a shiny, taut and hairless skin with translucent appearance ○ Quite resistant to healing, often maintenance wounds ● Diabetic ○ Occur because of neuropathic changes related to diabetes. includes: ■ Sensory neuropathy, loss of protective sensations (decreased ability to feel pain or temperature) ■ autonomic neuropathy ■ absence of sweating leading to dry skin with dissures, crack and calluses over pressure points ■ motor neuropathy, resulting in changes in muscle contractions leading to high arches and cocked-up hammer toes leading to pressure points for calluses ○ Common over bony prominences located on the plantar surface of foot, over the metatarsal heads, and beneath heals
emigration of leukocytes
● neutrophils will move to the sides of the blood vessels this is called migration or pavementing. Chemokines receptors and selectin help them stick and roll along capillary surfaces. Diapedesis begins within a few mins to hours of injury. The neutrophils are then attached by a process called chemotaxis. The neutrophils then consume dead tissue through phagocytosis. Eosinophils (release hydrolases which contribute to inflammation) and NK cells will recognize the infected cells.
1. What is the cause and effect of vascular permeability, emigration of leukocytes, and phagocytosis? 1) vascular permeability
● precapillary arteries contract briefly which causes a period of vasoconstriction is followed by a prolonged period of vasodilation, caused by a release of chemical mediators. Such as histamine, prostaglandin and leukotriene. The permeability then increases and floods get pushed out of the blood vessels contributing to inflammation and local swelling. Histamine is an early indication and releases powerful vasodilators that can causes a reduction in blood pressure it can also cause bronchoconstriction and mucus production. They are used widely in allergic responses Prostaglandins and leukotrienes are phospholipids so this creates vasodilation and increased permeability, they also may increase pain by enhancing the sensitivity of pain receptors. Platelets move into site and create a fibrin mesh to induce the clotting cascade
