CHAPTER 14 – OLDER ADULTS
Introduction to Older Adults
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People who are 65 years old are considered to be in the lower boundary for “old age” in the U.S.
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Chronological age often has little relation to the reality of aging for an older adult
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Each person ages in their own way; every older adult is unique
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As a nurse, you need to approach each older patient as an individual
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The number of older adults in the U.S. is increasing .
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This increase is caused by increase in average life span .
Variability Among Older Adults
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Greater variation in Physiological, cognitive, and psychosocial health with older adults
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Few have lost ability to care for themselves, are confused/withdrawn, or unable to make decisions concerning their needs
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most older adults remain functionally independent despite the increasing prevalence of chronic disease
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Most are active and involved in community
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Most older adults live in noninstitutional settings
Older adults are…
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MYTH: Mostly ill & disabled
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MYTH: Are always forgetful and easily confused
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MYTH: Are unable to understand and learn new information
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FACT: Are lifelong learners
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•
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MYTH: Mostly poor and experience poverty
MYTH: Are bored easily
MYTH: What other myth or stereotype do you hear?
Ageism: discrimination against people of increasing age, just as people who are racists and sexists discriminate because of skin color and gender
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current laws ban discrimination on the basis of age!
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Evaluate yourself and be aware of yourself before you help others
Community-Based and Institutional Health Care Services
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Nurses encounter older-adult patients in a wide variety of community and institutional health care settings:
o Clinics, private homes, apartments, retirement communities, adult day care centers, assisted-living facilities, nursing centers
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Nurses/social workers help older adults and families by providing info and answering questions as they make choices among care options
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Best way to evaluate quality of nursing center is for patient and family to visit and inspect it personally (tour)
Assessing the Needs of Older Adults
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Nursing assessment to ensure an age-specific approach
o Allow rest periods as needed or conduct assessment in several sessions if patient has reduced energy or limited endurance
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Take time to adjust patient, be gentle, divide the task out, provide comfort
o 3 key points for an “Age-specific approach”
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Interrelation between physical and psychosocial aspects of aging
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Effects of disease and disability on functional status
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Tailoring the nursing assessment to an older person
o Hearing impaired pt? make sure hearing aid works, face pt, speak in low pitch tones, quiet space, use alterative tools to help
o Visual impaired pt? make sure glasses/contact are UTD, stand out at eye level, use alternative tools
o Memory deficits? Grab info from family members instead
UTI in older adults – fever, dysuria, confusion, decreased LOC, irritation
UTI in younger adults – dysuria, flank pain, malodorous urine, angry
Physiological Changes
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Understanding older adult’s perception of health status is essential for accurate assessment & development of clinically relevant interventions
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Older adults’ concepts of health generally depend on personal perceptions of functional ability (ADLs).
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Understand the normal, more common changes to provide appropriate care for older adults!
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General survey
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Reproductive system
o Begins during initial nurse-patient encounter
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Urinary system
o Quick, but careful, head-to-toe scan
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Musculoskeletal system
o Presence of universal aging changes
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Neurological system
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Integumentary system
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Thorax and lungs
o Skin
o Respiratory muscle strength decreases
o Lesions
o Anteroposterior diameter of thorax ↑
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Head and neck
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Heart and vascular system
o Facial features
o ↓ contractile strength of the myocardium results in
o Visual acuity
↓ cardiac output
o Auditory changes
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Breasts
o Salivary secretion
o Tissue less firm
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Gastrointestinal system and abdomen
o Smaller, less dense, and less nodular breast
Functional Changes
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Functional status in older adults includes the day-to-day activities of daily living (ADLs) involving activities within physical, psychological,
cognitive, and social domains.
o ADLs: Examples? bathing, dressing, and toileting
o IADLs: instrumental ADLs Examples? the ability to write a check, shop, prepare meals, or make phone calls
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Changes are usually linked to illness or to disease and degree of chronicity.
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Occupational and physical therapists are your best resources for a comprehensive assessment.
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Factors that promote highest level of function:
o Healthy, well-balanced diet, paced/appropriate activity, regular doctor visits, regular participation in meaningful activities, use
of stress management techniques, avoidance of alcohol, tobacco, illicit drugs
Cognitive Changes
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Common MYTHs: “cognitive impairments are widespread in older adults” and “forgetfulness is an expected consequence of aging.”
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NOT NORMAL: disorientation, loss of language skills, loss of ability to calculate, poor judgment = REQUIRE FURTHER ASSESSMENTS!
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Standard assessment forms for patient’s mental status: Mini-Mental State Exam-2, Mini-Cog, and Clock Drawing test
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3 Conditions affecting cognition
o Delirium – acute confusional state – potentially reversible cognitive impairment that occurs suddenly and worsens at night
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Potentially reversible
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Medical emergency
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Often has a physiological cause (UTI, sepsis)
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Requires prompt assessment and
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Examples: Dementia is another
intervention
additional RF that greatly ↑the risk for
delirium; this can occur at the same time
o
o
Dementia – generalized impairment of intellectual functioning that interferes with social and occupational functioning
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Generalized impairment of intellectual function
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Umbrella term that includes: Alzheimer’s disease (most common type), Lewy body disease, frontal-temporal
dementia, and vascular dementia
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Gradual, progressive, irreversible decline in cerebral function
Depression – a mood disturbance characterized by feelings of sadness and despair
Psychosocial Changes
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Retirement
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Social isolation
o Risk factors: impaired sensory function, functional impairment, chronic illness, reduced mobility, and cognitive changes
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Sexuality - all older adults need to express their need for intimacy and sexual feelings
o What kind of open-ended question can you ask to elicit info and concerns related to sex and sexuality?
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“I know sexuality is important, can you tell me about your needs and wants?”
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Housing and environment (make sure it’s safe)
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Death - death of a spouse or significant other is the loss that most affects lives of older people
Health Promotion and Maintenance: to increase the desire for older adults to participate in health promotion, use an individualized approach,
taking into account a person’s beliefs about the importance of staying healthy and remaining independent.
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Difficulties with mobility were the most commonly reported limitations
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Teaching strategies:
o Ensure the patient is ready to learn. Be alert for cues of pain and fatigue.
o Create a comfortable environment (e.g., seating, temperature).
o Allow time to process information and ask questions.
o Adapt teaching materials for culture, language, and health literacy.
o Focus on concrete information and relate to past experiences as appropriate.
o Use printed materials with large black font on either cream or white paper.
o Use clear, concise language; avoid medical terminology.
o Use pictures, demonstrations, videos, and other methods to augment spoken language.
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General Preventive measures for older adults:
o Regular primary care, dental, vision, and hearing visits (if patient has a hearing aid)
o Participation in recommended screening activities as indicated by age (BP, mammography, depression, vision/hearing,
colonoscopy)
o Immunization for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease
o Regular exercise, smoking cessation, and stress management
o Attaining and maintaining target weight
o Eating a low-fat, well-balanced diet or adhering to a specific diet (e.g. diabetic diet, low-sodium diet)
o Moderate alcohol use
o Socialization
o Good handwashing
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Physiological Concerns
o
o
o
o
o
Heart disease
Cancer
Chronic lung disease
Stroke (CVA)
Smoking
o
o
o
o
o
Risk factors for falls in older adults
Intrinsic factors
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History of a previous fall
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Fear of falling
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Muscle weakness
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Impaired vision
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Postural hypotension
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Problems with balance and gait
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Adverse medication reactions (sedatives, hypnotics,
anticonvulsants, opioids)
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Chronic conditions, including arthritis, stroke, incontinence,
diabetes, Parkinson’s disease, dementia
Alcohol abuse
Nutrition
Dental problems
Exercise
Falls
o
o
o
Sensory impairments
Pain
Medication use
Extrinsic factors
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Poor lighting (interior and exterior)
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Lack of handrails on stairs (interior and exterior)
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Poor design of stairwells
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Lack of bathroom grab bars and nonslip surfaces
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Hazards and obstacles (furniture, cords, throw rugs) that
contribute to tripping
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Slippery or uneven surfaces
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Improper use of assistive devices
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Inappropriate footwear (smooth socks, flip flops)
Health Promotion and Maintenance: Psychosocial Concerns
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Elder mistreatment - intentional act or failure to act that causes or creates a risk for harm to an older adult
Type
Description
Examples
Occurs when older adults experience illness,
Hitting, beating, pushing, slapping, kicking, physical restraint,
Physical abuse
pain, or injury as the result of physical force
inappropriate use of drugs, fractures, lacerations, rope burns,
or the threat of physical injury.
untreated injuries
Psychosocial/
Verbal and nonverbal acts that inflict mental
Insults, threats, humiliation, intimidation, harassment, social isolation,
emotional abuse
pain, anguish, fear, and distress
destroying property
Illegal taking, misuse, or concealment of
Check cashing without permission, forging a signature, stealing money
money, benefits, property, or assets
or possessions, coercing a signature on legal documents (e.g., will,
Financial abuse
belonging to an elderly person
trust), forcing or improper use of durable power of attorney, unpaid
bills, unauthorized credit card use
Nonconsensual sexual contact or activity of
Unwanted touching, rape, sodomy, forced watching of pornography,
Sexual abuse
any kind; coercing an elder to witness sexual
coerced nudity, sexually explicit photography
behaviors
Refusal or failure by those responsible to
Refusal or failure to provide basic necessities such as food, water,
Neglect
meet basic needs
shelter, hygiene, and medical care
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Therapeutic communication - sitting down and engaging an older adult eye to eye
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Touch - provides sensory stimulation, induces relaxation, provides physical/emotional comfort, conveys warmth, communicates interest
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Reality orientation - communication technique that makes an older adult more aware of person, place, and time.
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Validation therapy - alternative approach to communication with an older adult who is confused.
o Whereas reality orientation insists that the confused older adult agree with statements of time, place, and person, validation
therapy accepts the description of time and place as stated by the older adult. You do not challenge or argue with statements
and behaviors of the older adult. Instead, the focus is the emotional aspect of the conversation, which represents an inner need
or feeling. For example, a patient insists that the day is actually a different day because of high anxiety. Caregivers should
acknowledge the distress the individual is experiencing. Validation does not involve reinforcing the older adult’s
misperceptions; it reflects sensitivity to hidden meanings in statements and behaviors. By listening with sensitivity and
validating what the patient is expressing, you convey respect, reassurance, and understanding. Validating or respecting older
adults’ feelings in the time and place that is real to them is more important than insisting on the literally correct time and place.
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Reminiscence – recalling the past
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Body-image interventions - way older adults present themselves influences body image and feelings of isolation
CHAPTER 36 – THE EXPERIENCE OF LOSS, DEATH, AND GRIEF
Loss - developing a personal understanding of your own feeling about grief and death will help you better serve your patients
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Necessary loss: they learn to expect that most necessary losses are eventually replaced by something different or better.
o Maturational loss: form of necessary loss and includes all normally expected life changes across the life span. Maturational
losses associated with normal life transitions help people develop coping skills to use when they experience unplanned,
unwanted, or unexpected loss.
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Situational loss: sudden, unpredictable external events
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Actual loss: occurs when a person can no longer feel, hear, see, or know a person or object.
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Perceived loss: is uniquely defined by the person experiencing the loss and is less obvious to other people.
Grief - normal but bewildering cluster of ordinary human emotions arising in response to a significant loss, intensified and complicated by the
relationship to the person or the object lost
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Normal (uncomplicated) grief is uncomplicated. This type of grief a common and universal reaction characterized by complex emotional,
cognitive, social, physical, behavioral, and spiritual responses to loss and death.
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Anticipatory grief before the actual loss or death occurs, especially in situations of prolonged or predicted loss like caring for patients
diagnosed with dementia or ALS.
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Disenfranchised grief when their relationship to the deceased person is not socially sanctioned, cannot be openly shared, or seems of
lesser significance.
o Ambiguous loss, a type of disenfranchised grief, occurs when the lost person is physically present but is not psychologically
available, as in cases of severe dementia or severe brain injury.
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Complicated grief, a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic
and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally
numb, or anxious about the future.
o Chronic - experiences a normal grief response except it extends for a longer period of time.
o Exaggerated - often exhibits self-destructive/maladaptive behavior, obsessions, or psychiatric d/o. Suicide is a risk for these individuals.
o Delayed or postponed because the loss is so overwhelming that the person must avoid the full realization of the loss.
o Masked grief is when a grieving person behaves in ways that interfere with normal functioning but is unaware that the
disruptive behavior is a result of the loss and ineffective grief resolution
Theories of Grief and Mourning
Denial - the person cannot accept the fact of the loss. It is a form of psychological protection from a loss that the person
cannot yet bear.
Stages of Dying
Anger - the person expresses resistance or intense anger at God, other people, or the situation.
Kübler-Ross (1969)
Bargaining - the person cushions and postpones awareness of the loss by trying to prevent it from happening.
Depression - the person realizes the full impact of the loss.
Acceptance - the person incorporates the loss into life.
Numbing - protects the person from the full impact of the loss
Yearning and Searching - emotional outbursts of tearful sobbing and acute distress; common physical symptoms in this
stage: tightness in chest and throat, shortness of breath, a feeling of lethargy, insomnia, and loss of appetite
Attachment Theory
Disorganization and Despair - endless examination of how and why the loss occurred or expressions of anger at anyone
Bowlby (1980)
who seems responsible for the loss
Reorganization - accepts the change, assumes unfamiliar roles, acquires new skills, builds new relationships, and begins
to separate himself or herself from the lost relationship without feeling that he or she is lessening its importance
Grief Tasks Model
Accepts the reality of the loss
Adjusts to a world in which the deceased is missing
Worden (2008)
Experiences the pain of grief
Emotionally relocates the deceased and moves on with life
Rando’s “R” Process Recognize the loss
Recollect and re-experience the relationship with the deceased
Model
React to the pain of separation
Readjust to life after loss
Rando (1993, 2014)
Relinquish old attachments
Reinvest by putting emotional energy into new people
Loss-Oriented activities: grief work, dwelling on the loss, breaking connections with the deceased person, and resisting
Dual Process Model
activities to move past the grief
Stroebe and Schut
Restoration-Oriented activities: attending to life changes, finding new roles or relationships, coping with finances, and
(1999)
participating in distractions, which provide balance to the loss-oriented state
Factors Influencing Loss and Grief
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Human development - age and stage of development affect the grief response
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Personal relationships - the quality and meaning of the lost relationship influence the grief response
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Nature of loss - exploring the nature of a loss will help understand the effects of the loss on the patient’s behavior, health, and well-being
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Coping strategies - may be health or unhealthy. Examples? Talking, journaling, sharing emotions with others, alcohol, drugs, violence
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Socioeconomic status - this influences a person’s grief process in direct and indirect ways
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Culture and ethnicity - it is necessary to ask about cultural beliefs and practices
o expressions of grief in 1 culture do not always make sense to people from a different culture
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Spiritual and religious beliefs - assess your patient’s beliefs and practices and encourage expression
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Hope - gives a person the ability to see life as enduring or having meaning or purpose
Implementation: Health Promotion
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Palliative care - focuses on prevention, relief, reduction, or soothing of symptoms of disease throughout entire course of illness
o FOCUS: comfort and improved quality of life, it is a valuable approach to caring for patients with a complex illness
o It can also include, but is not solely, care of the dying
o PRIMARY GOAL is to help patients and families achieve the best possible quality of life
o Should receive palliative care as soon as possible when chronic or terminal disease starts creating difficult-to-manage sxs.
o Palliative care is appropriate for patients of any age, with any diagnosis, at any time, and in any setting
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appropriate both for patients still receiving aggressive treatment with hope of achieving a cure and for patients who
have forgone any life extending treatment
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Hospice care - philosophy and model for care of redundant patients and families at the end of life.
o Priority: managing pain and symptoms, comfort, quality of life; attention to physical, psychological, social, and spiritual
needs/resources
o Usually for patients who have < 6 months to live
o Services available in home, hospital, extended care, and nursing homes
o The cornerstone of hospice care is trusting relationship between the hospice team and the patient and family. Knowing
expectations, desired location of care, and family dynamics help the hospice team provide individualized care at the end of life.
o Unlike traditional care, hospice patients are active participants in all aspects of care, and caregivers prioritize care according to
patient wishes
Physical changes hours/days before death
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Sleepiness/unresponsiveness
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Coolness and color changes in extremities, nose, fingers
(cyanosis, pallor, mottling)
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Bowel/bladder incontinence
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Decreased urine output – dark colored
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Restlessness, confusion, disorientation
Table 36.3 Promoting Comfort in the Terminally Ill Patient
Symptoms
Characteristics or Causes
Pain
Skin discomfort
Mucous
Membrane
discomfort
Corneal irritation
Fatigue
Anxiety
Nausea
Constipation
Diarrhea
Urinary
incontinence
Altered nutrition
Dehydration
Pain has multiple causes, depending on
patient diagnosis.
Any source of skin irritation increases
discomfort.
Mouth breathing or dehydration leads to dry
mucous membranes; tongue and lips become
dry or chapped.
Blinking reflexes diminish near death, causing
drying of cornea.
Metabolic demands, stress, disease states,
decreased oral intake, and heart function
cause weakness and fatigue.
Physical, social, or spiritual distress causes
anxiety; causes may be situational or event
specific.
Nausea is caused by medications, pain, or
decreased intestinal blood flow with
impending death.
Opioids, other medications, and immobility
slow peristalsis. Lack of bulk in diet or
reduced fluid is a cause.
Disease processes, treatment or medications,
and gastrointestinal (GI) infections are causes.
Progressive disease and decreased level of
consciousness are causes.
Medications, depression, decreased activity,
and decreased blood flow to GI tract are
causes. Nausea produces anorexia.
Patient is less willing or able to maintain oral
fluid intake; has fever.
Ineffective
breathing
patterns
(dyspnea, SOB)
Anxiety; fever; pain; increased oxygen
demand; disease processes; and anemia,
which reduces oxygen-carrying capacity, are
causes.
Noisy breathing
(“death rattle”)
Noisy breathing is the sound of secretions
moving in the airway during inspiratory and
expiratory phases caused by thick secretions,
decreased muscle tone, swallow, and cough.
•
•
•
•
•
Decreased intake of food/fluids; inability to swallow
Congestion/↑ pulmonary secretions; noisy respirations
Altered breathing (apnea, labored/irregular, Cheyne-stokes)
Decreased muscle tone, relaxed jaw muscles, sagging mouth
Weakness & fatigue
Nursing Implications
Collaborate with team members to identify and implement appropriate
pharmacological and nonpharmacological interventions to reduce pain
and promote comfort
Keep skin clean, dry, and moisturized. Monitor for incontinence.
Provide oral care at least every 2 to 4 hours. Apply a light film of lip balm
for dryness. Apply topical analgesics to oral lesions prn.
Optical lubricants or artificial tears reduce corneal drying.
Provide periods of rest and educate patient about energy conservation.
Provide opportunity for patient to express feelings though active listening.
Provide calm, supportive environment. Consult members of the health
care team to determine whether pharmacological interventions are
appropriate.
Determine the cause of nausea and work to reduce nausea triggers such
as strong smells. Administer antiemetics or promotility agents. Encourage
patients to lie on their right side. Provide oral care at least every 2-4 hours
Increase fiber in diet if appropriate. Administer stool softeners or laxatives
as needed. If possible, encourage increased liquid intake and regular
periods of ambulation.
Consult with members of the health care team to determine the cause
and make appropriate changes.
Provide skin care and easy accessibility to the toilet or bedside commode.
Provide good skin care and frequent assessment for incontinent urine.
Place Foley catheter as appropriate.
Encourage patient to eat small, frequent meals of preferred foods.
Patients should never be forced to eat.
Reduce discomfort from dehydration; give mouth care at least every 2 to
4 hours; offer ice chips or moist cloth to lips. Keep lips and tongue moist.
Treat or control underlying cause. Use nonpharmacological interventions
such as elevating the head of the bed to promote lung expansion.
Provide oxygen as needed. Keeping the air cool provides ease and comfort
for the terminal patient.
Using morphine or benzodiazepines to treat tachypnea is sometimes
appropriate.
Elevate head to facilitate postural drainage. Turn patient at least every 2
hours.
Provide oral care and maintain hydration as tolerated.
CHAPTER 43 - SLEEP
Physiology of Sleep
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Sleep: cyclical physiological process that alternates with longer periods of wakefulness
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Circadian rhythm: 24-hour, day-night cycle
o Temp., HR, BP, hormone secretion, sensory acuity, & mood depends on this
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Everyone has different biological clocks that synchronize their sleep cycles
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Sleep regulation
o Regulated by a sequence of physiological states integrated by central nervous system (CNS) activity
o Hypothalamus
o Reticular activating system (RAS)
o Homeostatic process (Process S)
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2 phases
o NREM sleep, nonrapid eye movement (75% of the night): 4 stages during typical 90 min. sleep cycle
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Stage 1 & 2: light sleep (easily aroused)
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Stage 3 & 4: deeper sleep or “slow wave” sleep (difficult to arouse)
▪
N1 (Formerly Stage 1)
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Stage of lightest level of sleep, lasting a few minutes.
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Decreased physiological activity begins with gradual fall in vital signs and metabolism.
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Sensory stimuli such as noise easily arouse sleeper.
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If awakened, person feels as though daydreaming has occurred.
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N2 (Formerly Stage 2)
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Stage of sound sleep during which relaxation progresses.
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Arousal is still relatively easy.
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Brain and muscle activity continue to slow.
▪
N3 (Formerly Stages 3 and 4)
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Called slow-wave sleep.
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Deepest stage of sleep.
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Sleeper is difficult to arouse and rarely moves.
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Brain and muscle activity are significantly decreased.
•
Vital signs are lower than during waking hours.
o REM sleep, rapid eye movement (25% of the night): Phase at end of each sleep cycle
▪
Increased brain activity with rapid eye movements, muscle atonia (dreams, muscle relax completely)
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Vivid, full-color dreaming occurs.
▪
Stage usually begins about 90 minutes after sleep has begun.
▪
Stage is typified by autonomic response of rapidly moving eyes, fluctuating heart and respiratory rates, and increased
or fluctuating blood pressure.
▪
Loss of skeletal muscle tone occurs.
▪
Gastric secretions increase.
▪
It is very difficult to arouse sleeper.
▪
Duration of REM sleep increases with each cycle and averages 20 minutes.
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A person usually passes through 4-6 complete sleep cycles, each cycle consisting of 3 stages of NREM sleep and a period of REM sleep, for
a total of 90-110 minutes
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With each successful cycle, stage 3 (combined 3 & 4) of NREM sleep shortens, and REM sleep lengthens
REM, Rapid eye movement.
Insomnias
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Adjustment sleep disorder (acute insomnia)
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Inadequate sleep hygiene
Sleep-Related Breathing Disorder
Central Sleep Apnea Syndromes
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Primary central sleep apnea
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Central sleep apnea caused by medical condition
Box 43.2 Classification of Select Sleep Disorders
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•
Behavioral insomnia of childhood
Insomnia caused by medical condition
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Obstructive sleep apnea syndromes
Hypersomnias of Central Origin (Not Caused by a Sleep-Related Breathing Disorder)
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Narcolepsy (four specified types)
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Hypersomnia caused by a medical condition
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Menstrual-related hypersomnia
Parasomnias - Disorders of Arousal
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Sleepwalking
Parasomnias Usually Associated With REM Sleep
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Nightmare disorder
•
•
Sleep terrors
REM sleep-behavior disorder
Other Parasomnias
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Sleep-related hallucinations
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Sleep-related eating disorder
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Sleep-related enuresis (bed-wetting)
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Advanced–sleep phase type
Behaviorally-Induced Circadian Rhythm Sleep Disorders
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Jet lag type
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Shift work type
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Drug or substance use
Sleep-Related Movement Disorders
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Restless legs syndrome
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Periodic limb movements
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Sleep-related bruxism (teeth grinding)
Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues
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Long sleeper
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Short sleeper
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Sleep talking
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Environmental sleep disorder
Circadian Rhythm Sleep Disorders
Primary Circadian Rhythm Sleep Disorders
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Delayed–sleep phase type
Other Sleep Disorders
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Physiological (organic) sleep disorders
Sleep Disorders
▪
Insomnia - sxs when person has chronic difficulty falling asleep, frequent awakenings from sleep, and/or a short/nonrestorative sleep
o Most common sleep related complaint, esp. in women, commonly with depression
o Signals underlying physical or psychological disorder
o Often associated with poor sleep hygiene
o Treatment: symptomatic, biofeedback, cognitive techniques, relaxation techniques
▪
most common, 30% adults experience this
▪
d/t stress, activity, meds
▪
feel sleepy, depressed, anxiety throughout the day
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Sleep Apnea - disorder characterized by lack of airflow through nose and mouth for 10 secs. To 1-2 minutes in length
o 3 types: obstructive (most common), central, and mixed
o 2 Major risk factors: obesity and hypertension
▪
Other: smoking, increasing age, HF, alcohol, structural abnormalities, large neck circumference, and menopause
o OSA occurs when muscles of oral cavity/throat relaxes during sleep = upper airway partially or completely blocked = diminishing
nasal airflow (hypopnea) or stops (apnea) for as long as 30 seconds
o The person tries to breathe because chest and abdominal movements continue, which often results in loud snoring and
snorting sounds. When breathing is partially or completely diminished, the person becomes sufficiently hypoxic and must
awaken to breathe. Structural abnormalities such as a deviated septum, nasal polyps, narrow lower jaw, or enlarged tonsils
sometimes predispose a patient to OSA.
o Common complaints: excessive daytime sleepiness and fatigue
o OSA may contribute to high BP and risk for MI and stroke
o Central sleep apnea: dysfunction in respiratory control center of brain
▪
Narcolepsy - dysfunction of mechanisms that regulate sleep and wake states
o Characteristics:
▪
Excessive daytime sleepiness is the most common complaint
▪
During day: person feels overwhelming wave of sleepiness and falls asleep = REM sleep occurs within 15 mins.
▪
Cataplexy: sudden muscle weakness/loss of muscle tone during intense emotions occurs at any time during day
▪
Sleep paralysis, sleeping at inappropriate times
o Treated with stimulants, wakefulness promoting agents, antidepressant meds that suppress cataplexy
o Other treatments: Brief 20-minute naps, regular exercise program, good sleep habits, timing daytime naps, eating light meals
high in protein, deep breathing, gum chewing, taking vitamins
▪
Sleep Deprivation - decrease in quantity or quality of sleep and/or inconsistency in timing of sleep
o Causes: illnesses, emotional stress, meds, environmental disturbances, variability in timing of sleep (work)
▪
Sleep apnea or insomnia can cause this as well
o Associated with obesity, type 2 diabetes, poor memory, depression, digestive problems, development of cardiovascular disease
BOX 43.3. sleep-deprivation symptoms
Physiological Symptoms
Psychological Symptoms
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Ptosis, blurred vision
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Decreased reasoning and judgement
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Confused and disoriented
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Agitated
•
Fine-motor clumsiness
•
Decreased auditory and visual
•
Increased sensitivity to pain
•
Hyperactive
•
Decreased reflexes
alertness
•
Irritable, withdrawn,
•
Decreased motivation
•
Slowed response time
•
Cardiac arrhythmias
apathetic
•
Excessive sleepiness
Normal Sleep Requirements and Patterns – total daily sleep time
•
Neonates (up to 3 months): 16 hours
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School-age children: varies; 9-12 hours
•
Infants (by 3 months): 15 hours total with naps
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Adolescents: 8-10 hours recommended
•
Toddlers (by 2 y/o): 12 hours total with a nap
•
Young adults: 6-8.5 hours per night
•
Preschoolers: 12 hours per night
•
Middle adults: 7-9 hours per night
•
Older adults: varies; many have sleep problems
Older adults spend more time in stage 1 and less time in stages 3 and 4 (NREM sleep); some older adults have almost no NREM stage 4 or deep
sleep. Episodes of REM sleep tend to shorten. Older adults experience fewer episodes of deep sleep and more episodes of lighter sleep. They tend
to awaken more often during the night, and it takes more time for them to fall asleep. To compensate they increase the number of naps taken
during the day.
Older adults who have a chronic illness often experience sleep disturbances. For example, an older adult with arthritis frequently has difficulty
sleeping because of painful joints. Changes in sleep pattern are often caused by changes in the CNS that affect the regulation of sleep. Many older
adults with insomnia have co-morbid psychiatric illness or medical conditions, take medications that disrupt sleep patterns, or use drugs or alcohol.
Sensory impairment reduces an older person’s sensitivity to time cues that maintain circadian rhythms.
Factors Influencing Sleep
•
Lifestyle - work schedule, social activities, routines
•
Usual sleep patterns - may be disrupted by social activity or work schedule
•
Emotional stress - worries, physical health, death, losses
•
Environment - noise, routines, ventilation, bed, room temperature
•
Exercise and fatigue - moderate exercise and fatigue cause a restful sleep
•
Food and calorie intake - time of day, caffeine, nicotine, alcohol, spicy meal, tea
o Weight loss = insomnia
o Weight gain = OSA
•
Drugs and substances - hypnotics, diuretics, narcotics, antidepressants, alcohol, caffeine, beta-blockers, anticonvulsants
BOX 43.4 Drugs and Their Effects on Sleep. REM, Rapid eye movement.
Implementation
•
Health promotion
o Environmental controls: noise, lighting
o Promoting bedtime routines: quiet activities
o Promoting safety: night lights, infant safety
o Promoting comfort: voiding, blankets
o Promoting activity: active during day
•
Acute care
o Environmental controls
o Promoting comfort
o Establishing periods of rest and sleep
•
Restorative or continuing care
o Promoting comfort
o Controlling physiological disturbances
o
o
o
Stress reduction: relaxing activity
Bedtime snacks: warm milk, cocoa, no caffeine
Pharmacological approaches: melatonin, Valerian,
chamomile
o
o
Promoting safety
Stress reduction
o
Pharmacological approaches
CHAPTER 44 – PAIN MANAGEMENT
PAIN: is purely subjective
•
Nurses are legally and ethically responsible for assessing and managing pain.
o IASP’s definition: ”an unpleasant, subjective sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage”
o McCaffery’s definition: “Pain is whatever the experiencing person says it is, existing whenever he says it does”
Physiologic response:
•
Stress response stimulates the autonomic nervous system, which stimulates the SNS, resulting in physiologic responses
•
Pain of low to moderate intensity and superficial pain elicit the SNS. Continuous, severe, deep pain activates the PSNS.
•
Do patients in pain always have changes in vital signs?? No
•
Table 44.1 Physiological Reactions to Pain
o Increase HR, RR
o Peripheral vasoconstriction
o Dilation of pupils
o Increased blood glucose
o Diaphoresis
o Decreased GI motility
Patient’s self report of pain is the single most reliable indicator of its existence and intensity
Types of Pain
•
Acute/transient pain
o identifiable cause
o protective in nature
o limited tissue damage and
o self-limiting
(warning of injury)
emotional response
o short duration
•
Chronic/persistent noncancer pain
o Not protective in nature
o ex. arthritis, LBP, HA, fibromyalgia, peripheral neuropathy
o Last more than 3-6 months
o assoc sxs: fatigue, insomnia, anorexia, weight loss,
o Not always have an identifiable cause
apathy, hopelessness, depression, anger
o Usually, non-life threatening
o GOAL: improve functional status with a
o Major cause of psychological (suicide) and physical
multimodality plan
disability (interferes with ADLs, socialization)
•
Chronic episodic pain – pain that occurs sporadically over an extended period of time
o ex. migraine HA that occurs up to 14 days per month vs. chronic migraine that occurs more than 15 days per month
•
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.
o ex. complex regional pain syndrome (CRPS)
•
Cancer pain – is not experienced by all patients with cancer.
o is normal (nociceptive), d/t stimulus of an undamaged nerve, and/or neuropathic, arising from abnml or damaged pain nerves
o Usually caused by tumor progression & related pathological processes, invasive procedures, toxicities of chemotherapy, infection
▪
A patient can experience referred pain.
Characteristics of pain
•
Timing (onset, duration, and pattern)
•
Location
Table 44.5 Classification of Pain By Location
Pain scales
•
Numerical
•
Descriptive
•
•
Severity (pain scale from 0 to 10)
Quality
•
•
•
•
Aggravating and precipitating factors
Relief measures
Visual analog
Wong-Baker Faces Pain Scale - ages 3 and older
Non-pharmacological interventions - can be used alone or in combination with pharmacological measures
•
Evidence-based therapies include acupuncture and massage, osteopathic and chiropractic manipulation, cognitive-behavioral intervention,
meditative movement and mind-body interventions, and dietary and self-management approaches to pain management
•
Examples:
o Cognitive-behavioral interventions change pts’ perceptions of pain, alter pain behavior & provide pts with a greater sense of control
▪
Distraction, prayer, mindfulness, relaxation, guided imagery, music, and biofeedback
▪
May be inappropriate for the cognitively impaired
o Physical approaches can = pain relief, correct physical dysfxn, alter physiological responses, ↓ fear assoc w/pain-related immobility
▪
complementary and alternative medicine (CAM) therapies like touch & mindfulness meditation can help alleviate pain
▪
ex. heat (for chronic pain), cold (for acute pain, but no direct application and apply no longer than 5 minutes),
transcutaneous electrical nerve stimulation [TENS] focus on promoting comfort and altering physiological responses to
pain and are generally safe and effective
•
•
•
•
•
Relaxation and guided imagery allows patient to alter affective-motivational and cognitive pain perception
o Relaxation is mental/physical freedom from tension or stress that provides a sense of self-control
▪
Meditation, yoga, Zen, guided imagery, relaxation exercises
o Physiological/behavioral changes with relaxation:
▪
↓ HR, BP, RR, O2 consumption, heightened awareness, sense of peace, ↓ muscle tension and metabolic rate
Distraction - with sufficient sensory stimuli, a person ignores or becomes unaware of pain
o People who are bored or in isolation have only their pain to think about
o Distraction directs a patient’s attention to something other than pain and thus reduces awareness of it
Music - useful for acute or chronic pain, stress, anxiety, and depression
o Creates positive changes in mood and emotional states
Cutaneous stimulation
o Stimulation of skin through massage, warm bath (for chronic pain), cold application (for acute pain, but no direct application and
apply no longer than 5 minutes), or transcutaneous electrical nerve stimulation (TENS) may reduce pain perception
▪
May cause release of endorphins, blocking transmission of painful stimuli
▪
Do not use directly on sensitive skin areas (burns, bruises, skin rashes, inflammation, underlying bone fractures)
Herbals - may interact with prescribed analgesics; ask patients to report all substances they take
- Always evaluate the pain intervention
o Examples: echinacea, ginseng, ginkgo biloba, garlic
Pharmacologic Pain Therapies - Analgesics
▪
Nonopioids for mild-to-moderate acute pain
o Acetaminophen – analgesic and antipyretic, not anti-inflammatory; can cause hepatotoxicity
o NSAIDs – analgesic, antipyretic, anti-inflammatory; can cause GI bleed
▪
Opioids (narcotics) for moderate-to-severe pain
o Morphine, codeine, hydromorphone, fentanyl, oxycodone, hydrocodone (oral formulations)
▪
most common side effects of opioids:
Central Nervous System (CNS) Toxicity
•
Thought and memory impairment
•
Drowsiness, sedation, and sleep disturbance
•
Confusion
•
Hallucinations, potential for diminished psychomotor performance
•
Delirium
•
Depression
•
Dizziness and seizures
Ocular
•
Pupil constriction
Respiratory
•
Bradypnea
•
Hypoventilation
Cardiac
•
Hypotension
•
Bradycardia
•
Peripheral edema
Gastrointestinal
•
Constipation
•
Nausea and vomiting
•
Delayed gastric emptying
▪
after an appropriate period of time
- Oral meds usually peak in about 1 hour
- IVP meds usually peak in 15-30 minutes
- Evaluate if patient has an adverse effect
Genitourinary
•
Urinary retention
Endocrine
•
Hormonal and sexual dysfunction
•
Hypoglycemia—reported with tramadol and methadone
Skin
•
Pruritus
Immunological
•
Immune system impairment possible with chronic use
Musculoskeletal
•
Muscle rigidity and contractions
•
Osteoporosis
Pregnancy and Breastfeeding
•
When at all possible, avoid opioid use during pregnancy to
prevent fetal risks
Tolerance
•
Over time, increased doses needed to obtain analgesic effect
Withdrawal Syndrome
•
Rapid or sudden cessation or marked dose reduction may
cause rhinitis, chills, pupil dilation, diarrhea, “gooseflesh”
Adjuvants or co-analgesics - drugs originally developed to treat conditions other than pain but that also have analgesic properties
o have analgesic properties, enhance pain control, or relieve other symptoms associated with neuropathic pain
o can be given alone or with analgesics
o ex. tricyclic antidepressants, anticonvulsants (gabapentin), lidocaine
Patient-controlled analgesia (PCA)
▪
Drug delivery system that allows patients to self-administer opioids with minimal risk of overdose
o Pt. can push button to deliver dose
o Limit on number of doses/hour or 4-hour interval may be set
o No need to wait for nurse
o Have locked safety systems for potential tampering by pts or fam
▪
GOAL: maintain constant plasma level of analgesic to avoid problems of prn dosing
▪
Benefits: pt gains control over pain, pt does not depend on nurse availability, assess to meds, ↓ anxiety, ↓ medication use
Topical and Transdermal Analgesics include prescription and OTC creams, gels, sprays, liquids, patches, or rubs applied on the skin over painful
muscles or joints and for peripheral neuropathy
▪
Topical agents work locally, have few side effects, and must be applied directly over the painful area.
▪
Transdermal drugs are also applied directly to the skin but have systemic effects and work when applied away from the area of pain.
o is absorbed through the skin by the bloodstream over a period of time.
▪
Do not place topical or transdermal analgesics on wounds, damaged skin, or the face. Wear disposable gloves when removing and applying
transdermal patches. Lastly, after application, wash your hands thoroughly to avoid getting these products in sensitive areas such as the eyes
Local anesthesia via injection - local infiltration of an anesthetic medication to induce loss of sensation to a body part
▪
Often use local anesthesia during brief surgical procedures such as removing a skin lesion or suturing a wound by applying local anesthetics
topically on skin and mucous membranes or injecting them subcutaneously or intradermally to anesthetize a body part.
▪
produce temporary loss of sensation by inhibiting nerve conduction & block motor and autonomic functions, depending on the amount used
and the location and depth of administration = pt loses sensation before losing motor fxn; conversely, motor activity returns before sensation
Epidural Analgesia - preservative free opioids are often administered as single agents or in combination w/ local anesthetics into a pt’s epidural space
▪
effectively treats acute postoperative pain, rib fracture pain, labor and delivery pain, and chronic cancer pain.
▪
controls or reduces severe pain and reduces a patient’s overall opioid requirement, thus minimizing adverse effects.
▪
inserting a blunt-tip needle into the level of the vertebral interspace nearest to the area requiring analgesia
o risk of bleeding and subsequent epidural hematoma formation near the injection/insertion site
Cancer pain & chronic noncancer pain management - can be either chronic or acute
▪
Experts agree that cancer pain is still not adequately treated
▪
Analgesics for chronic pain should be prescribed on a regular basis and not on “as required” or prn schedule
▪
Long acting or controlled release meds may provide relief for all types of chronic pain, including cancer pain (morphine, oxycodone)
▪
Many patients with cancer experience breakthrough cancer pain (BTCP), a transitory ↑ in pain in someone who has relatively stable and an
adequately controlled level of baseline pain
o Incident pain: Pain that is predictable and elicited by specific behaviors or triggers, such as a voluntary act (walking), involuntary act
(coughing), or treatments (e.g., wound dressing changes)
o End-of-dose failure pain: Pain that occurs toward the end of the usual dosing interval of a regularly scheduled analgesic
o Spontaneous pain: Pain that is unpredictable and not associated with any activity or event
Barriers to effective pain management. BOX 44.20
Physical Dependence - a state of adaptation that is manifested by a drug class–specific withdrawal syndrome produced by abrupt cessation, rapid dose
reduction, decreasing blood level of the drug, and/or administration of an antagonist.
▪
Common symptoms of opioid withdrawal include shaking, chills, abdominal cramps, excessive yawning, and joint pain.
Addiction - a primary, chronic, neurobiological disease with genetic, psychosocial, environmental factors influencing its development & manifestations.
▪
behaviors include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving
Drug Tolerance - a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over
time. “Need higher and higher dose to control pain.”
CHAPTER 43 – FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Fluid distribution
Extracellular fluid (ECF): outside cells (1/3 of total body water)
•
3 divisions:
o Intravascular fluid: liquid part of blood
o Interstitial fluid: between cells and outside blood vessels
o Transcellular fluid: CSF, pleural, peritoneal, synovial fluids secreted by epithelial cells
Intracellular fluid (ICF): inside cells (About 2/3 of total body water)
Composition of body fluids
Osmolality of a fluid: measure of # of particles per kilogram of water
•
Isotonic solution: fluid with same tonicity as normal blood
•
Hypotonic solution: more dilute than blood
•
Hypertonic solution: more concentrated than normal blood
Fluid Balance
Fluid intake
Fluid distribution
Fluid output normally occurs through four organs: the skin, lungs, GI tract, and kidneys and is influenced by
•
Antidiuretic hormone (ADH) - causes renal cells to resorb water and put it back in the blood
o People normally have some ADH release to maintain fluid balance.
o More ADH is released if body fluids become more concentrated.
o Where is ADH made? In the posterior pituitary gland (hypothalamus)
o Factors that increase ADH: severely decreased blood volume (e.g., dehydration, hemorrhage), pain, stressors, meds
Too much ADH = SIADH; too little ADH = diabetes insipidus
•
Renin-angiotensin-aldosterone system (RAAS) - regulates ECF volume by how much Na+ & water are excreted in urine
o contributes to regulation of BP
o To maintain fluid balance, normally some action of the RAAS occurs
o Renin – angiotensinogen – angiotensin I – angiotensin II – aldosterone
o Aldosterone circulates to the kidneys, where it causes resorption of Na+ and water in isotonic proportion in the distal renal tubules.
▪
Removing sodium and water from the renal tubules and returning it to the blood ↑ the volume of the ECF
▪
▪
↑ Na+/water in blood & excretes K+ in urine
Where is aldosterone secreted from? Adrenal cortex
Too much aldosterone? Cushing’s disease; Too little aldosterone? Addison’s disease
•
Atrial natriuretic peptide (ANP) - regulates ECV by influencing how much Na+ & water are excreted in urine
o Where is ANP secreted from? Atrium (heart)
o ANP in heart inhibits ADH = ↑ loss of Na+ & water in urine
▪
Cells in the atria of the heart release ANP when they are stretched (e.g., by an ↑ ECV). ANP is a weak hormone that
inhibits ADH by ↑ the loss of sodium and water in the urine.
▪
ANP opposes the effect of aldosterone.
▪
What disease would cause ANP to be secreted? Heart failure, MI, CAD, HTN, CVA
Fluid Imbalances
•
Extracellular volume imbalances
o Deficit: insufficient isotonic fluid in extracellular compartment
▪
Output of isotonic fluid exceeds intake of Na+ containing fluid
▪
↑ BUN
▪
↑ hematocrit
▪
↑ sodium
▪
↓ UOP
o Excess: too much isotonic fluid in extracellular compartment
▪
Intake of sodium-containing isotonic fluid has exceeded fluid output
▪
↓ BUN
▪
↓ hematocrit
▪
↓ sodium
▪
? UOP
•
Osmolality imbalances
o Hypernatremia, “water deficit”; hypertonic
o Hyponatremia, “water excess”; hypotonic
•
Clinical dehydration
o ECV deficit and hypernatremia combined
↓↓ TABLE 42.3 FLUID IMBALANCES ↓↓
Osmolality imbalances - body fluids become either hypertonic or hypotonic
•
Na = think neuro changes!
•
Normal value: 135-145 mEq/L
•
Hypernatremia (water deficit): hypertonic condition
o Causes: loss of more water than salt OR gain of more
salt than water
o Water leaves cells = shrivel
•
Hyponatremia (water excess): hypotonic condition
o Causes: gain of more water than salt OR loss of more
salt than water
o Water enters cells by osmosis = swell
Electrolyte Balance
•
Intake and absorption
•
Distribution
o Plasma concentrations of K+, Ca2+, Mg+, and phosphate (Pi) are very low compared with their concentrations in cells and bone.
o Concentration differences are necessary for normal muscle and nerve function.
•
Output
o Urine, feces, and sweat
o Vomiting, drainage, and fistulas
TABLE 42.4 ELECTROLYTE INTAKE AND ABSORPTION, DISTRIBUTION, AND OUTPUT
TABLE 42.5 ELECTROLYTE IMBALANCES
Know how to calculate ABGs!!!
•
•
pH: 7.35-7.45
PaCO2: 45-35 mmHg
o
o
•
Partial pressure of Co2
Measure of how well lungs are excreting CO2 produced by cells
HCO3-: 22-26 mEq/L
o
Concentration of base bicarbonate
Measure of how well kidneys are excreting metabolic acids
45 - 35
45 - 35
TABLE 42.7 Acid-Base Imbalances
Respiratory acidosis - the lungs are unable to excrete enough CO 2
Respiratory alkalosis - the lungs excrete too much carbonic acid
Respiratory acid-base imbalance problem? Only lungs can correct
problem it, but kidneys can try to compensate
Metabolic acidosis- occurs from an increase of metabolic acid or a ↓ of base
Metabolic alkalosis - occurs from a direct increase of base (HCO−
3 ) or a decrease
of metabolic acid
•
Respiratory acid-base imbalance problem? Only lungs can correct it, but
kidneys can try to compensate
Metabolic acid-base imbalance problem? Only kidneys can correct problem it, but
lungs can try to compensate
Physical Assessment
•
Daily weights - important indicator of fluid status
o Weigh patient same time each day with same scale after a patient voids. Use same clothes.
•
Fluid intake and output (I&O)
o 24-hour I&O: compare intake versus output (2 should be almost equal)
o Intake = all liquids eaten, drunk, received through IV, feeding tubes, blood
o Output = Urine, diarrhea, vomitus, gastric suction, wound drainage
TABLE 42.10 Focused Nursing Assessments for Patients with Fluid, Electrolyte, and Acid-Base Imbalances
Implementation
•
Acute care
o Enteral replacement of fluids
o Restriction of fluids
▪
Pts w/ hyponatremia usually require restricted H2O intake
o Parenteral replacement of fluids and electrolytes
▪
Parenteral nutrition (PN), also called total PN (TPN): IV administration of complex, highly concentrated solution
containing nutrients and electrolytes to meet patient’s needs
•
Administered through CVC with high osmolality or PIV for lower osmolality solutions
•
Usually PN solutions >10% dextrose requires a CVC
IV Therapy (crystalloids) (table 42.11 on pg 3274)
•
IV therapy: need order for type, amount, and rate of solution
•
Types of solutions (table 42-11, pg 956)
o Isotonic (iso = equal, tonic = concentration of solution)
▪
Same effective osmolality as body fluids
▪
Ex 0.9% NaCl or NS, LR (lactated ringers), D5W* (odd-ball - isontonic when enters the vein, RBCs love dextrose, dextrose
enters RBCs. both isotonic and hypotonic)
▪
NS indicated to treat ECV deficit; good initial
treatment, hydration before procedure
▪
Does not mess with the cell!*
▪
Uses: N/V/D (dehydration), blood loss, surgery, burns
o Hypotonic: effective osmolality less than body fluids
▪
Ex: 0.45% NaCl, 0.225% NaCl – diluted coffee
▪
Helps move water into cells = CELL SWELLS, can burst
▪
Uses: cells are dehydrated (DKA), patients with
hypertension (water moves from vessels to RBCs;
↓ BP), hypernatremia
▪
RISK: can make patient hypovolemic and lower BP;
Don’t give to patients with high cranial pressure or
burns!!! Watch for cellular edema!
o Hypertonic: effective osmolality greater than body fluids – thick coffee
▪
Helps move water out of cells
= CELL SHRIVELS = move out of cells + back into vessels
▪
Examples: D10W, 3% or 5% NaCl, D5 in 0.45% NaCl,
D5 in 0.9% NaCl, D5LR
▪
RISK: hard on the veins, usually given in ICU,
can increase BP
▪
Uses: cerebral edema, hyponatremia (too much water, not enough sodium)
•
Primary (those that we hang, NS, LR, D5W, D10W) and secondary IV fluids (piggyback on top of the primary)
o Once secondary flows into the patient, the primary will follow
o The higher = the greater the force of gravity
Table 42.11 IV Solutions
A number indicates the percent of grams of solute per 100 mL; for example, D5 = 5% dextrose or 5 grams of dextrose per 100 mL of solution.
Vascular Access Devices (VADs)
•
Catheters or infusion ports designed for repeated access to vascular system
o Peripherally inserted central catheters (PICC lines): enter peripheral arm vein and extend to superior vena cava
o Equipment: sterile
o Initiating a PIV
o Regulating the infusion flow rate (mL/hour)
▪
Use electronic infusion devices (EIDs)
o Maintaining the system
o Changing intravenous fluid containers, tubing, and dressings
▪
Follow INS standards
o Helping patients to protect intravenous integrity
o Complications of intravenous therapy
▪
Infiltration
▪
Extravasation
▪
o Discontinuing peripheral intravenous access
▪
Stop the medication, REMOVE/DISCONTINUE THE catheter so no more blood/med gets into the patient
Phlebitis
Blood Transfusion
•
Blood component therapy = IV administration of whole blood or blood component like PRBCs, platelets, plasma
•
Check blood groups and types, VS, labs, expiration date, 7 rights
•
Autologous transfusion
•
Transfusing blood
o Pretransfusion assessments…
o 18-20 gauge catheter with 0.9% NaCl
o Before beginning transfusion…
o First 15-minute assessments
o Verify 3 things
o How long can you transfuse blood? 4 hours maximum
•
Transfusion reaction: immune system reaction that ranges from mild response to severe anaphylactic shock or acute intravascular hemolysis
= fatal (If incompatible blood is transfused (i.e., a pt’s RBC antigens differ from those transfused), the pt’s antibodies trigger RBC destruction)
If you suspect a reaction:
•
Stop the transfusion immediately.
•
Keep the IV line open by replacing the IV tubing down to the catheter hub with new tubing and running 0.9% sodium chloride (normal saline)
at a slow rate.
•
Do not turn off the blood and simply turn on the 0.9% sodium chloride (normal saline) that is connected to the Y-tubing infusion set. This
would cause blood remaining in the IV tubing to infuse into the patient. Even a small amount of additional blood can make the situation
worse. You must change out all the IV tubing.
•
Immediately notify the health care provider or emergency response team.
•
Remain with the patient, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
•
Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, corticosteroids per health care provider order or protocol.
•
Prepare to perform cardiopulmonary resuscitation.
•
Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank.
•
Obtain blood and urine specimens per health care provider order or protocol.
Blood Groups and Types
Blood transfusions must be matched to each patient to avoid incompatibility. RBCs have antigens in their membranes; the plasma contains antibodies
against specific RBC antigens. If incompatible blood is transfused (i.e., a patient’s RBC antigens differ from those transfused), the patient’s antibodies
trigger RBC destruction in a potentially dangerous transfusion reaction(i.e., an immune response to the transfused blood components).
The most important grouping for transfusion purposes is the ABO system, which identifies A, B, O, and AB blood types. Determination of blood type is
made on the basis of the presence or absence of A and B RBC antigens. Individuals with type A blood have A antigens on their RBCs and anti-B
antibodies in their plasma. Individuals with type B blood have B antigens on their RBCs and anti-A antibodies in their plasma. A person who has type AB
blood has both A and B antigens on the RBCs and no antibodies against either antigen in the plasma. A type O individual has neither A nor B antigens
on RBCs but has both anti-A and anti-B antibodies in the plasma shows the compatibilities between blood types of donors and recipients. People with
type O-negative blood are considered universal blood donors because they can donate packed RBCs and platelets to people with any ABO blood type.
People with type AB-positive blood are called universal blood recipients because they can receive packed RBCs and platelets of any ABO type.
Another consideration when matching blood components for transfusions is the Rh factor, which refers to another antigen in RBC membranes. Most
people have this antigen and are Rh positive; a person without it is Rh negative. People who are Rh negative receive only Rh-negative blood
components.
KAHOOT QUESTIONS
Kubler stage of dying - full impact of loss in the stage of depression
anticipatory grief - person exp emotions before the actual loss happens
hope can energize and provide comfort to individual and families experiencing personal challenges
situational loss - exp sudden emotional, unpredictable external events
in hospice care the pt who are accepted generall have only 3 months to live FALSE - it is 6 months
REM sleep - characterized by vivid full color dreams
sys of sleep deprevation - hyperactive, excessive sleepiness, blurred vision
•
NOT: increased reflexes
not benefit of PCA pump: family can deliver dose
•
benefit: self admin, minimal overdose risk, assess to medication
some patients with cancer will experience both acute and chronic pain. TRUE
not a common side effect of opioids? increased mental functioning
•
YES: decreased respiration, decreased mental functioning, hypotension
extra/intracellular electrolytes