Healing and Episode - Part 2.docx

Notes **[Lived Experience Part 1:]** Guidelines for understanding gender-based violence: 1. 2. 3. 4. - - - - - - - 1. - - - - - - - - - - - - Hyperarousal: - - - - - - - Hypoarousal: - - - - - -...

Notes **[Lived Experience Part 1:]** Guidelines for understanding gender-based violence: 1. 2. 3. 4. - - - - - - - 1. - - - - - - - - - - - - Hyperarousal: - - - - - - - Hypoarousal: - - - - - - - Grounding: - - - - - - - - - - Validate experiences: - - - - - - - - Know support services: - - - Clinical counselling: - Shelter: - Outreach team: - Family court support program Second stage housing Empower the survivor: - - - - Indigenous people: - - - Effects of colonization: - - - Residential schooling: - - - - Historical trauma: - - - - Failed attempt to assimilate: - - - The healing: - - - - - - - - - - - **[Lived Experience Part 2:]** History of trans: - - - - - Canadas notable moments: - - - - - - Terminology: - - - - - - - - - - - - - - - - - Challenges: - - - - - - - - Being a good ally: - - - - - - Image: - - - - - - - - - - - - - - - - - **[The perioperative experience: ]** Types of surgery: - - - - - Types of surgery - purpose: - - - - - Types of surgery - urgency: - - - - - Types of surgery - degree of risk: - - - - FACTORS EFFECTING THE RISK: - - - - - - Types of surgery: - - - - - - - - - Perioperative phase: Interprofessional team: - - - - - - - - - - - - - - - - - - - - Perioperative - nurses major responsibility: - - - - - - - Nursing assessment: - - - - - - - - - - - - - - - - Medication history - hazardous to surgery: - - - - - - - Physical assessment/clinical manifestations: - - - - - - - - - - - - - - - - - - - Gerontological considerations: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Psychosocial considerations: - - - Laboratory and diagnostics: - - - - - - - - - - - - - - Pre-operative nursing diagnosis: - - - - - - Pre-operative teaching: - - - - - - - - - - - - - - - - - - - - - Legal preparation: - - - - - - - - - - - - - - - - Day-of-surgery preparation: - - - - - - - - - - - - - - - - - - - - - Pre-operative medications: - - - - - - - - - Transportation to the OR: - - - - - - Intraoperative phase: - - Intraoperative team: - - - - - Nursing responsibilities before surgery (before OR): - - - - - - Nursing responsibilities during surgery (in OR): - - - - - - - - - - - - - - - - Safety in the OR: - - - - - - - - - Nursing responsibilities after surgery: - - - - - - Attire in the OR: 3 zones: 1. 2. 3. - - - - - - Anethesia: General anesthetics: - - - - - - LOCAL, REGIONAL OR SPINAL ANESTHETICS - - - - - - - - - Spinal Anesthesia: - - - - - - - - - - - - - Potential intra-op adverse events: - - - - - - - - - - - Gerontological considerations: - - - - - - - Post-operative phase: - - - - - - Post-Anesthesia Care: Operating Room → Post Anesthesia Care Unit (PACU) - - - - - - - Post-op nursing goals: - - - - - - - - Post-op unit preparation: - - - - - - - - - - Post-operative laboratory and diagnostic testing: - - - - - - - - - Post-operative care - Nutrition: - - - - - - Postoperative care - complications: - - - - - - - - - - - - - - - - - - Gerontologic considerations: - - - - - - **[Post - Operative Complications - Hemorrhage]** **Deep Vein Thrombosis** - - - - - **Deep Veins** - - - Venous Thrombus \[singular\]/Thrombi \[plural\] - - - - Contributing Factors: Virchow's Triad 1. 2. 3. Predisposing Factors: Venous Stasis - - - - - - - - - - - Predisposing Factors: Vessel Wall Injury - - - - - - Predisposing Factors: Altered Blood Coaguability - - - - - - Predisposing Factors: Others - - - - - - - Upper Extremity Venous Thrombosis - - - - - - - - Prophylaxis: Doctor's Orders **Anticoagulation** - - - - **Mechanical** - - Pneumatic Compression Device/Sequential Compression Device - - - Elastic Stockings -- TED -- Thromboembolic Device Hose or thigh high anti-embolic Stocking - - - - - Nursing Considerations \[for both\]: - - - Calf Circumference Unilateral in calf circumference can be an early indication - - - **Body positioning + position change** - Don't: - - - - - Exercise -- activity = contraction of skeletal muscles -- puts pressure on veins to promote venous return -- decreases stasis Prevent thrombi - antiembolic exercises q1h w/a - - - - Others: - - - Clinical Manifestations -- Superficial Veins - - - - Treatment - - - - Clinical Manifestations - DVT - - - - - - - Suspected DVT: Reported Immediately - - - **[Diagnostics]** **Duplex Ultrasonography** - **D-dimer Blood Test** - **Contrast Venography** - **MRI/CT** - Goal of DVT Management 1. 2. 3. **[Treatment Options]** **Pharmacological Therapy:** **Anticoagulant Therapy** - - **Thromboembolytic Therapy** **Surgical Treatment:** - - - - Anticoagulation Agents: **Unfractionated Heparin** - - - - - - - What is the antidote for Heparin? 1. 2. 3. 4. - Heparin Induced Thrombocytopenia \[HIT\] - - - - - - - Anticoagulation Agents: Low-Molecular-Weight Heparin (LMWH) - - - - - - - **Fondaparinux \[Arixtra\]** - - - - - Anticoagulation Agents: Oral Anticoagulants - - - - What is the antidote for warfarin (Coumadin)? 1. 2. 3. 4. Anticoagulation Agents: Systemic Thrombolytic Therapy - - - - - - Surgical Management When: 1. 2. 3. Such as \[many reasons\]: bleeding, severe trauma, severe liver or renal disease, CVA, L+D + + + + Options: - - - - Anticoagulation - - - - - - - - **Blood Work** INR=International Normalized Ratio.9 -1.1 aPTT= activated partial prothrombin time 28-38 seconds PT=prothrombin time 10-14 seconds Platelets 150-400 x 10 9th/L Hemoglobin (HGB) Male 135-170 g/L Female 115-160 g/L Hematocrit (HCT) Male.4-.51 Female.34-.48 Anticoagulation Therapy Monitoring **Bleeding** - - - - What else do we need to consider?????? - - - - - - Anticoagulation Therapy Monitoring **Thrombocytopenia - Decrease in platelets -** 150-400 x 109/L - - - - - Anticoagulation Therapy Management **Numerous Drug Interactions:** - - - - - - - Anticoagulants - Teaching - - - - - - - Anticoagulants - Teaching - - - - - - - - Client Comfort and Healing Adjuncts to Therapy: - - - - - - - Pulmonary Embolism - - - PE Pathway\...\...\...\...\...\...\...\...\...\... - - - - PE Risk Factors - - - - - - - - - - PE - - - - - PE\...\...\...\...\...continued Leads to\...\...\...\...\... - - - Prevention Prevent DVT Major Elective Surgery - Active thrombotic process or undergoing major ortho, prostatectomy, eye or brain surgery - Signs and Symptoms (PE) - - - - - - - - - Diagnostic Tests and Assessment - - - - - - - - Interventions - - - - - Pharmacolgical Therapy: Anticoagulation - - - - - - Pharmacological Therapy: Thrombolytics - Thrombolytic Therapy - - - - - - - - - Blood work checked first, heparin stopped, no invasive procedures -- after, started on anticoagulants Surgery - - - Management Preventing Thrombus: - - - - - - Hemmorhage - Hemo = blood orrhage = burst forward Loss of large amount of blood externally or internally in a short period of time - - - - - Hemorrhage - - - Time frame: - - - - Common causes: - - - Classification of Hemorrhage **Type of Vessel** - - - **Visibility** - - - WHO Grading to Measure Bleeding 1. 2. 3. 4. Signs and Symptoms - - - - - - - - - - Nursing Interventions: team approach, control bleed, adequate circulating blood volume, prevent shock, assess cause! **External** - - - - **Internal** - - - - - - Consider -- client safety and special considerations r/t blood loss replacement **Complications of surgery - shock:** What is shock: - - - - Pathophysiology of shock: - - - - - - - - - - - - - Overview of shock: - - - Stages of shock: - - - Compensatory stage of shock: - - - - - - Clinical signs - compensatory stage: Finding Compensatory stage ------------------- ------------------------------- Blood pressure Normal parameters for patient Heart rate \> 100 bpm Respiratory rate \> 20 breaths/min skin Cold, clammy Urinary output Decreased Mentation Confusion Acid-base balance Respiratory alkalosis Progressive stage of shock: - - - - - - - - - - - Clinical signs - progressive stage: Finding Progressive stage ------------------- --------------------------------------------- Blood pressure Systolic \ 150 bpm Respiratory rate \> 30 breaths/min; rapid, shallow, crackles skin Mottled, petechiae Urinary output Substantially decreased; 0.5mL/kg/hr Mentation Lethargy Acid-base balance Metabolic acidosis Irreversible Stage of Shock: - - - - - - - - Clinical signs - irreversible stage: Finding Irreversible stage ------------------- --------------------------------------- Blood pressure Mechanical/pharmacologic support Heart rate Erratic Respiratory rate Intubation and mechanical ventilation skin Jaundice Urinary output Anuric; requires dialysis Mentation Unconscious Acid-base balance Profound acidosis Classifications of shock: LOW BLOOD FLOW: - - - - - - MALDISTRIBUTION OF BLOOD FLOW: - - - - - - - Hypovolemic Shock - - - - - Hypovolemic Shock Clinical Manifestations - - - - - - - Interventions - - - - Cardiogenic Shock - - - - Cardiogenic Shock Clinical Manifestations - - - - - - - - Interventions - - - - - - Distributive Shock - - - 1. 2. - Septic Shock - - - - - SIRS Criteria - - - - - - Septic Shock - - - - - - - - - - - - - - - Neurogenic Shock - - - - - - - - - Neurogenic Shock - - - - - - - - - - - - - Anaphylactic Shock - - - - Anaphylactic Shock - 1. 2. 3. Anaphylactic Shock - - - - - - - - - - - - - - - - - Children in Shock - - - - Children in Shock - - - - - - - Therapeutic Management - - - - - - - - **Fluid and electrolytes:** Distribution of Body Fluids: - - - - - - - - - - Fluid Distribution and Age - - Solutes -- dissolved particles - - - - Electrolyte concentration: - - - Normal electrolyte content and body fluids: Electrolytes (Anions and Cations) Intravascular (mEq/L) Interstitial (mEq/L Intracellular (mEq/L) ----------------------------------- ----------------------- --------------------- ----------------------- Sodium (Na+) 142 146 15 142 146 15 Potassium (K+) 5 5 150 5 5 150 Calcium (Ca++) 5 3 2 5 3 2 Magnesium (Mg++) 2 1 27 2 1 27 Chloride (Cl−) 102 114 1 102 114 1 Bicarbonate (HCO3−) 27 30 10 27 30 10 Phosphate (HPO4−2) 2 2 100 2 2 100 Sulfate (SO4−2) 1 1 20 1 1 20 Homeostasis - - - - Water movement: Fluid Tonicity (Osmosis) - - - Movement of Body Fluids Between ICF & ECF: - - - - - - - - Regulation of Body Fluids - - - - - - - - - - - +-----------------------+-----------------------+-----------------------+ | | Diabetes insipidus | SIADH | +=======================+=======================+=======================+ | Causes | Hypothalamic tumors, | Oat-cell carcinoma of | | | leukemia, | the lung, leukemia, | | | | head injury, | | | lymphoma, | | | | sarcoidosis, head | brain tumor, | | | | pneumonia, acute | | | trauma or hypoxic | respiratory failure, | | | brain injury, | | | | | tuberculosis, release | | | general anesthetics | of vasopressin after | | | | surgery, | | | | | | | | stroke, spinal | | | | surgery | +-----------------------+-----------------------+-----------------------+ | pathophysiology | ADH deficiency | Inappropriate | | | leading to | secretion of ADH with | | | | water retention | | | polyuria and | | | | polydipsia; excretion | creating hypotonic | | | | ECF and water | | | of large volumes of | movement inside | | | dilute urine | | | | | cells, causing | | | | neurologic symptoms | +-----------------------+-----------------------+-----------------------+ | Laboratory findings | Normal serum sodium | Low serum sodium and | | | and | osmolarity, low BUN | | | | and | | | osmolarity if thirst | | | | mechanisms | creatinine, increased | | | | urine osmolarity and | | | intact; if not, high | specific | | | serum sodium | | | | | gravity, normal | | | and osmolarity; low | adrenal and thyroid | | | urine specific | function | | | | | | | gravity | | +-----------------------+-----------------------+-----------------------+ | Signs and symptoms | Polyuria, nocturia, | Weight gain, | | | continuous | fingerprinting edema | | | | (cellular edema), | | | thirst, polydipsia, | | | | craving ice | no peripheral edema, | | | | Other S&Ss depend on | | | water | the | | | | | | | | Sodium level | +-----------------------+-----------------------+-----------------------+ | treatment | Oral hydration; may | Mild hyponatremia: | | | require ADH | fluid restriction and | | | | increased salt | | | replacement with | | | | vasopressin | intake | | | | | | | | Severe hyponatremia | | | | and CNS symptoms | | | | (e.g., | | | | | | | | seizures): saline (3% | | | | or 5% NaCl) in | | | | addition to fluid | | | | | | | | restriction and | | | | furosemide | +-----------------------+-----------------------+-----------------------+ Hypovolemia - - - - +-----------------+-----------------+-----------------+-----------------+ | Imbalance | Contributing | S & S | Lab findings | | | factors | | | +=================+=================+=================+=================+ | Fluid Volume | Loss of water & | Acute wt loss, | Increased hgb | | | electrolytes | | and | | Deficit | | decreased skin | | | | (vomiting, | turgor, | hct, increased | | (hypovolemia) | diarrhea, | | serum | | | fistulas, | oliguria, | | | | | concentrated | and urine | | | fever, excess | | osmolality | | | sweating, | urine, weak | | | | | rapid | and specific | | | burns, blood | | gravity, | | | loss, GI | pulse, \>cap | | | | suction, | refill, low | decreased urine | | | | | | | | 3rd space fluid | CVP, | sodium, | | | shifts; and | hypotension, | increased | | | | flat | | | | decreased | | BUN and | | | intake | neck veins, | creatinine, | | | (anorexia, | dizzy, | | | | | | increased urine | | | nausea, no | weak, increased | | | | access to | thirst, | specific | | | fluid). | | gravity and | | | | confusion, | | | | Diabetes | | osmolality | | | insipidus | tachycardia, | | | | | muscle | | | | | | | | | | cramps, sunken | | | | | eyes | | +-----------------+-----------------+-----------------+-----------------+ | Fluid Volume | Compromised | Acute wt. gain, | Decreased hgb | | | regulatory | | and | | Excess | | peripheral | | | | mechanisms: | edema and | hct, decreased | | (hypervolemia) | renal failure, | | serum | | | | ascites, | | | | heart failure, | distended | and urine | | | and cirrhosis; | | osmolality, | | | | jugular veins, | | | | overzealous | | decreased urine | | | admin of Na+ | crackles, | | | | | elevated | sodium and | | | fluids, fluid | | specific | | | shifts (burns), | CVP, SOB, | | | | | | gravity | | | prolonged | hypertension, | | | | corticosteroid | | | | | | bounding pulse, | | | | therapy, severe | | | | | stress, | cough, | | | | | tachypnea | | | | hyperaldosteron | | | | | ism | | | +-----------------+-----------------+-----------------+-----------------+ Fluid volume deficit; Nursing Care - - - - - - - - - - - - - - - Hypervolemia - - - +-----------------+-----------------+-----------------+-----------------+ | Imbalance | Contributing | S & S | Lab findings | | | factors | | | +=================+=================+=================+=================+ | Fluid Volume | Loss of water & | Acute wt loss, | Increased hgb | | | electrolytes | | and | | Deficit | | decreased skin | | | | (vomiting, | turgor, | hct, increased | | (hypovolemia) | diarrhea, | | serum | | | fistulas, | oliguria, | | | | | concentrated | and urine | | | fever, excess | | osmolality | | | sweating, | urine, weak | | | | | rapid | and specific | | | burns, blood | | gravity, | | | loss, GI | pulse, \>cap | | | | suction, | refill, low | decreased urine | | | | | | | | 3rd space fluid | CVP, | sodium, | | | shifts; and | hypotension, | increased | | | | flat | | | | decreased | | BUN and | | | intake | neck veins, | creatinine, | | | (anorexia, | dizzy, | | | | | | increased urine | | | nausea, no | weak, increased | | | | access to | thirst, | specific | | | fluid). | | gravity and | | | | confusion, | | | | Diabetes | | osmolality | | | insipidus. | tachycardia, | | | | | muscle | | | | | | | | | | cramps, sunken | | | | | eyes | | +-----------------+-----------------+-----------------+-----------------+ | Fluid Volume | Compromised | Acute wt. gain, | Decreased hgb | | | regulatory | | and | | Excess | | peripheral | | | | mechanisms: | edema and | hct, decreased | | (hypervolemia) | renal failure, | | serum | | | | ascites, | | | | heart failure, | distended | and urine | | | and cirrhosis; | | osmolality, | | | | jugular veins, | | | | overzealous | | decreased urine | | | admin of Na+ | crackles, | | | | | elevated | sodium and | | | fluids, fluid | | specific | | | shifts (burns), | CVP, SOB, | | | | | | gravity | | | prolonged | hypertension, | | | | corticosteroid | | | | | | bounding pulse, | | | | therapy, severe | | | | | stress, | cough, | | | | | tachypnea | | | | hyperaldosteron | | | | | ism | | | +-----------------+-----------------+-----------------+-----------------+ Fluid Volume Excess - - - - - - - - - - - Nursing considerations: - - - - Fluid volume Excess; Collaborative Care Management - - - - - - - Fluid volume Excess; Nursing Care - - - - - - - - - - - - Electrolyte balance - - - - - - - - Regulation of Sodium - - - - Hyponatremia - - - - - - Depletional Hyponatremia - - - - - Dilutional Hyponatremia - - - - - Clinical Manifestations of Hyponatremia - - - - - - Collaborative Care Management of ↓Na+ - - - - - - - - - Nursing Care of ↓Na+ - - - - - - - Hypernatremia - - - - - - Hypernatremia - - - - - - - - - - Clinical manifestations of Hypernatremia - - - - - - - Treatment of Hypernatremia - - - - - - - - - - - - Potassium - - - - - - - - - Hypokalemia - - - Causes of Hypokalemia - - - - - - - Clinical manifestations of Hypokalemia - - - - - - - - Hyperkalemia - - - - - - - - - Clinical manifestations of Hyperkalemia - - - - Treatment of Hyperkalemia - - - - - - - - pH - - - - - - - - Regulation of Acid-Base Balance - - - - - Acid-Base Balance Measurement - - - - - - - - - - - - - Types of Acid--Base Imbalances - - - - - - - - - - - - **SHOCK** Complications of Surgery: Shock **What is Shock?** - - - - **Pathophysiology of shock** - - - - - **Pathophysiology of shock** \*\*Recall, glucose is required for cellular energy (ATP) - - - - - - - **Overview of Shock** What 3 components does adequate blood flow to tissues require? 1. 2. 3. - - - **Stages of Shock** - - - **Compensatory Stage of Shock** - - - - - - **[Clinical Signs -- Compensatory Stage]** Finding - Compensatory Stage Blood Pressure Normal - parameters for patient Heart rate- \> 100 bpm Respiratory rate - \> 20 breaths/min Skin- Cold, clammy Urinary output - Decreased Mentation - Confusion Acid-base balance - Respiratory alkalosis **Progressive Stage of Shock** - - - - - - - - - - - **[Clinical Signs -- Progressive Stage]** Finding - Progressive Stage Blood Pressure - Systolic \ 150 bpm Respiratory rate \> 30 breaths/min; rapid, shallow, crackles Skin - Mottled, petechaiae Urinary output - Substantially decreased; 0.5mL/kg/hr Mentation - Lethargy Acid-base balance - Metabolic acidosis **Irreversible Stage of Shock** - - - - - - - - Clinical Signs -- Irreversible Stage Finding - Irreversible Stage Blood Pressure - Mechanical/pharmacologic support Heart rate - Erratic Respiratory rate- Intubation and mechanical ventilation Skin - Jaundice Urinary output - Anuric; requires dialysis Mentation- Unconscious Acid-base balance- Profound acidosis **CLASSIFICATIONS OF SHOCK** +-----------------------------------+-----------------------------------+ | **LOW BLOOD FLOW** | **MALDISTRIBUTION OF BLOOD FLOW** | +===================================+===================================+ | HYPOVOLEMIC | SEPTIC | | | | | Low Circulating Volume Secondary | Septicemia Secondary To Endotoxin | | | | | To Hemorrhage, Burns, | Release, Most Commonly Gram | | | Negative | | Dehydration, Third Spacing | | | | Bacteria | +-----------------------------------+-----------------------------------+ | CARDIOGENIC | NEUROGENIC | | | | | Pump Failure Secondary To Acute | Spinal Shock Secondary To Spinal | | | Cord | | MI, PE, Ventricular Aneurysm | | | | Injury, Anesthesia | +-----------------------------------+-----------------------------------+ | | ANAPHYLACTIC | | | | | | Acute, Life-threatening Allergic | | | Reaction | | | | | | To A Specific Antigen | +-----------------------------------+-----------------------------------+ **Hypovolemic Shock** - - - - - Decreased intravascular volume ➡ Decreased venous return ➡ Decreased stroke volume ➡ Decreased cardiac output ➡ Decreased tissue perfusion **Hypovolemic Shock** +-----------------------------------+-----------------------------------+ | Clinical Manifestations | Interventions | +===================================+===================================+ | - - - - - - - | - - - - | +-----------------------------------+-----------------------------------+ **Cardiogenic Shock** - - - - **Cardiogenic Shock** +-----------------------------------+-----------------------------------+ | **Clinical Manifestations** | **Interventions** | +===================================+===================================+ | - - - - - - - - | - - - - - - | +-----------------------------------+-----------------------------------+ **Distributive Shock** - - - 1. 2. - Precipitating Event ➡ Vasodilation ➡ Activation of inflammatory response ➡ Maldistribution of intravascular volume ➡ Decreased venous return ➡ Decreased cardiac output ➡ Decreased tissue perfusion **Septic Shock** - - - - - **SIRS Criteria** (\*\* these may vary based on agency) Clinical criteria used to identify SIRS - - - - **\ Septic Shock** +-----------------------------------+-----------------------------------+ | **Clinical Manifestations** | Interventions | +===================================+===================================+ | - - - - - - | - - - - - - - | +-----------------------------------+-----------------------------------+ **Neurogenic Shock** - - - - - - - - - **Neurogenic Shock** +-----------------------------------+-----------------------------------+ | **Clinical Manifestations** | **Interventions** | +===================================+===================================+ | - - - - - | - - - - - - | +-----------------------------------+-----------------------------------+ **Anaphylactic Shock** - - - - Three defining characteristics of anaphylaxis: 1. 2. 3. **Anaphylactic Shock** +-----------------------------------+-----------------------------------+ | **Clinical Manifestations** | **Interventions** | +===================================+===================================+ | - - - - - - - - - | - - - - - | | - | | +-----------------------------------+-----------------------------------+ **Children in Shock** - - - - - - - - - - - **Therapeutic Management** Goal - Assess and restore blood flow/tissue perfusion - - - - - - - **Sickle Cell Anemia** - - **Experience of Pain: Acute Pain Assessment and Management Alternative + Complementary Methods of Pain Control** **Rights of People with Pain** - - - **What is the purpose of declaring pain to be the 5th vital sign?** 1. 2. 3. 4. **Definitions of Pain** **The International Association for the Study of Pain** \...\....an unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such damage. **McCaffery** \...\...pain is whatever the experiencing person says it is, existing whenever he says it does. \.....to accept a client's report of pain, respect that report and to proceed with appropriate assessment and treatment. **Clients Who Cannot Self- Report** The **[inability]** to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain- relieving treatment. IASP Combination of pain evaluation techniques: 1. 2. 3. 4. Nursing Best Practice Guideline: Assessment And Pain Management RNAO Revised 2013 Under Review - 2024 - As a nurse, you are ethically responsible for managing pain and relieving suffering. - You are also legally and ethically obligated to advocate for change in the care plan when pain relief is inadequate. **The Concept of Pain** - - - - - - **Types of Pain - duration & etiology** - - - - **ACUTE PAIN IS\...\...\...** - - - - - - **Chronic Pain** - - - - 1. 2. **Benefits of Effective Pain Management** - - - - - - **Physiology Of Pain Nociceptors** - - Activated by: - - - **Classification of Pain** **Nociceptive Pain - Normal processing of stimuli** A. - - - B. - - **Neuropathic Pain- Abnormal processing of sensory input** Examples: - - - **Idiopathic Pain** **Nociceptive Pain** 1. 2. 3. 4. **Gate-Control Theory of Pain** - - - **Potential barriers to effective pain assessment and management?** - - - **Factors Influencing Pain** - - - - - **Nursing responsibilities and accountabilities r/t pain** - - - - - - +-----------------------+-----------------------+-----------------------+ | Sample \#1 - PQRST | Sample \#2 - Pained | Sample \#3 - Old Cart | +=======================+=======================+=======================+ | P -- provoking or | P -- place/ | O -- onset -- when | | | location(s) | did the pain start? | | precipitating | | | | | A -- amount | L -- location -- | | Q -- quality of pain | | where is your pain? | | | I -- intensifiers | | | R -- radiation of | | D -- duration -- | | pain | N -- nullifiers - | persistent, periodic? | | | what makes the pain | | | S -- severity of the | better | C -- characteristics | | pain | | -- what does it feel | | | E -- effects | like? | | T -- timing | | | | | D --descriptors | A -- aggravating | | | | factors - what makes | | | | the pain worse? | | | | | | | | R -- relieving | | | | factors -- what makes | | | | the pain better? | | | | | | | | T -- treatment - what | | | | medications work for | | | | you ? | | | | | | | | \- do you have | | | | adverse | | | | | | | | effects | | | | | | | | from your | | | | medications? | +-----------------------+-----------------------+-----------------------+ **Pain Assessment Tools** Visual Analog: Place a mark on a line from 'no pain' to worst pain' FACES: happy/sad/crying faces **EXAMPLES OF PAIN ASSESSMENT TOOLS** - **Responses to Pain** **Affective** - - - **Behavioral** - - - - **What will the nurse consider/incorporate in their teaching plan?** - - - - - - - - - **Physiological Responses** Acute pain is a warning to the body! - - - - - - - **Terms to Remember** - - - - - - **Acute Pain is reassessed\...\...\...\...\...** 1. 2. 3. 4. World Health Organization Analgesic Ladder **Three main principles:** - - - **Drug Therapy** Non-opioids➡ Opioids ➡ Adjuvants/ Co-analgesics ★ Multimodal analgesic -- more than 1 form of analgesia concurrently to obtain more pain relief with fewer opioids and less side effects. Two general categories: Simple analgesics and NSAIDS Examples: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (4g max/24 h, hepatotoxicity) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (headache/muscle strain) **What do NSAIDS do?** **NSAIDs block a specific enzyme called cyclooxygenase (or COX) used by the body to make prostaglandins.** By reducing production of prostaglandins, NSAIDs help relieve the discomfort of fever and reduce inflammation and the associated pain. **Chronic NSAID use in the older adult can have adverse effects such as**: NSAID use increases the risk of peptic ulcer disease, acute renal failure, and stroke/myocardial infarction. Pharmacological Pain-Relief Interventions - **Opioids** - - - - - - - Step1 Drugs: - Step 2 Drugs: - - - Step 3 Drugs: - Non-opioid ± adjuvant Weak opioid ± non- opioid ± adjuvant Strong opioid ± non-opioid ± adjuvant All steps may include adjuvants/co-analgesics (eg. antidepressants, anti-inflammatories, muscle-relaxants) Caution with meperidine (Demerol) neurotoxicity r/t accumulation of metabolite normeperidine **Routes** - - - - - - - INJECTION KITS: - - - Elderly Considerations - - - - - - True or False - **Facial expression** - **Pain Assessment Tools** - **Assessment of Non Verbal** - - - - - - **Pharmacologic Pain Management** Why might children may not complain of pain? - - - - - - **Severe Pain Children** - - - - - **Breakthrough Pain** - - **Types**: **Incident Pain:** predictable - elicited by specific behaviors **End-of-dose Failure Pain:** occurs towards end of usual dosing **Spontaneous Pain/Idiopathic Pain:** cause not readily identifiable **Cancer Pain** - - - - - - - - - **Opioids** Tolerance - Physical Dependence - Addiction - - - - - Patient Controlled Analgesia (PCA) - - - - - - - - - - - **Epidural Analgesia** - - - - - - **Nursing Considerations** - - - - - **Collaboration with patients and families is required in making pain management decisions (BPG, 2013). FAMILY/CAREGIVER ROLE** What role can family/caregivers play? - - - - - - **Non-pharmacological Pain Therapy** - - - **Complementary or Alternative** **[Complementary]** - **[Alternative]** - **Non-pharmacological Approaches** - - - - - - **CNO views complementary therapies as:** - - - - **Nursing Accessible Therapies Relaxation-** mental and physical freedom - - - - - **Guided Imagery** - - - - - **Progressive Relaxation Exercises** - - - - - - - - **Distraction** - - - - - - **Training-Specific Therapies** **Biofeedback** - instrumentation to mirror psychophysiologic processes that an individual is not normally aware of but may be able to bring under voluntary control. **Therapeutic touch** - practitioner uses his/her hands in the client\'s energy field to bring that field to balance and harmony - any physical illness can be viewed as an imbalance in this energy field. **Training-Specific Therapies - Reiki** **Chiropractic** - manipulate the body\'s alignment to relieve pain and improve function and to help the body heal itself. **Acupuncture** - thin needles into soft tissue -- replace pain with sensations of warmth, tingling or pressure. **Herbal Therapy** - Some herbs may interact with drugs you are receiving for pain or other conditions and may harm your health. **Comfort Therapy** - - - - - - - - - - **PT + OT Therapy** - - - **Psychosocial Therapy/counseling** - - - - - **Non-Pharmacological Methods For Children (RNAO)** - - - - - - - - - - **Neuropathic Pain and Mirror Therapy** - **COLD + HEAT THERAPIES** **Heat** - - - Cold - - **Transcutaneous Electrical Nerve Stimulation (TENS)** - - - - - **Controlling Painful Stimuli in the Client's Environment** - - - - - **Routine Clinical Approach to Pain Assessment and Management: ABCDE** A\....**[Ask]** about the pain regularly. Assess pain **systematically** B\....**[Believe]** the client and family in their report of pain and what relieves it C\....**[Choose]** pain control options appropriate for client, family and setting D\....**[Deliver]** interventions in a timely, logical and coordinated manner E\....**[Empower]** clients and their families. Enable them to control their course to the greatest extent possible