Chapter 28
What factors can influence pain?
Emotions, previous pain experience, sociocultural factors, communication and cognitive impairments, life stage.
How often should you turn patients to protect their skin and complications of immobility?
Every 2 hours
What is defined as mild to no activity and the person feels refreshed.
Rest
During a wound assessment you note formation of granulation tissue, that easily bleeds when performing wound care. What phase of wound healing would this be considered?
Proliferative phase
A patient who has a skin injury should be encourage to maintain/increase intake of?
Proteins
What are some examples of non-pharm pain relief measures?
Acupuncture, TENS units, massage, Temp. therapy, cognitive-behavioral interventions, immobilization.
What are some proper body mechanics to avoid injury?
Minimize bending and twisting of back, keep objects close to your body, squat to lift heavy objects, use wide base of support (feet spread apart), get help.
Dreaming and mental/emotional restoration occurs during this sleep.
REM sleep.
When performing a skin assessment you note full thickness skin loss extending down to fascia, what level pressure injury would this be considered?
Stage III
What is the difference between acute and chronic pain?
-Acute- pain that is short in duration, rapid onset, and may last up to 6 months.
-Chronic- persistent pain that lasts 3-6 months or longer, often interferes with ADL's.
What are some non-verbal indicators of pain?
- Increased HR, Increase systolic BP, and Increase respiration
-Facial grimacing
-Guarding
-Eating and sleeping poorly
-Irritability
What does a well rounded fitness program include?
Flexibility, resistance training, and aerobic conditioning.
Characterized by excessive daytime sleepiness, or falling asleep at times and in situations they need to be awake and alert.
Hypersomnia
A patient after surgery falls and has a total separation at the incision site with viscera protruding out, what is the term used for this complication?
Evisceration
This wound involves full thickness skin loss, and the base of wound is obscured by slough and eschar. What kind of pressure injury is this?
Unstageable pressure injury
What are side effects of Opioid pain relief and treatment?
-Constipation- Add more fiber to diet, exercise, fluid intake, stool softener.
- Nausea and Vomiting- reduce dose, antiemetic, relaxation techniques.
-Respiratory Depression- assess, reduce dose, Naloxone.
-Drowsiness- assess, educate, discontinue other nonessential CNS depressant med.
What is important to remember when creating a fitness program with patient?
Activity and exercise abilities are individualized, goals must consider the patient’s current condition, expected condition changes, lifestyles, and values.
What are some Interventions to promote sleep.
- schedule nursing care
- create a restful environment
- promote comfort
- support routines
- bedtime snacks (bread, milk, cheese)
- promote relaxation
You receive report that an older adult patient who is mobility impaired has been in a supine position all day. You would assess which areas for pressure injuries?
Back of head (Occipital bone), Scapulae, Elbow (Olecranon process), Sacrum, Heels (Calcaneus)
What is one of the most important steps when emptying a JP Drain
Re-compressing drain and closing it to reestablish suction and prevent contamination.
What are the different origins of pain and their meanings?
-Cutaneous (Superficial)- arise in skin or subQ tissue. (Burn or abrasion)
-Visceral- stimulation of deep internal pain receptor. Not well localized (tight, pressure, crampy pain).
-Deep somatic- originates from ligaments, tendons, nerves, bones. (fracture, sprain, arthritis)
-Radiating- starts at origin but extends to other locations. (Heartburn or sore throat).
-Referred- occurs in area distant from original site. (heart attack).
-Phantom- pain perceived from area that has been surgically removed. (amputation)
-Psychogenic- pain arsing from the mind though there is no physical cause.
A patient who is a quadriplegia would need what time of exercises?
Passive range of motion (PROM)
Name three examples of when people can have a disturbed circadian rhythm.
- People who work evening/night shifts
- changing time zones
- Hospitalization
Your patient has a chronic wound around the inner ankle with reddend/brown surround skin, irregular margins, shallow, and pain with leg dependence. What type of wound would this be considered?
Venous stasis ulcer
What precautions should be performed for patient and nurse during Airborne precautions?
Isolation room with negative pressure, keep room door closed, Don N-95, have patient wear mask if transporting.