Critical Thinking, Clinical Judgment, and Decision Making PDF

Critical Thinking, Clinical Judgment, and Decision Making Critical Thinking Critical thinking is the cognitive ability to think in a systematic and logic manner with openness to question and reflect on the reasoning process. The aim is to focus on important issues in a clinical situ...

Critical Thinking, Clinical Judgment, and Decision Making Critical Thinking Critical thinking is the cognitive ability to think in a systematic and logic manner with openness to question and reflect on the reasoning process. The aim is to focus on important issues in a clinical situation and make decisions that produce desired patient outcomes (Potter et al., 2023, p. 211). Critical thinking is a way of thinking about a clinical situation by asking questions to 1) help solve a problem or 2) make a clinical decision. Critical thinkers use their knowledge base, personal and professional experience, environmental factors, and critical thinking attitudes and standards. Critical Thinking and the Nursing Process There is a framework these two processes make that allows nurses to make a clinical decision based on patient needs. By applying critical thinking to a nursing process, clinical judgment is created. 5/2022  1 What is the Nursing Process? The nursing process is described by the American Nurses Association (ANA) as the framework nurses use to apply critical thinking in nursing practice for making clinical decisions (ANA, 2021). The nursing process is described below, but within those steps are 6 cognitive skills that help novice nurses improve their critical thinking and clinical judgment skills. The steps of the nursing process are: Gather information: Consider biophysical, Recognize Cues and psychological, sociocultural, spiritual, and determine what matters 1 Assess environmental characteristics. most. Evaluative judgment with the use of clinical Analyze Cues and determine reasoning to identify suspected problems by what it could mean. 2 Diagnose clustering similar cues of collected data Outcome What do you expect the end result to be? Prioritize Hypotheses and 3 Identification determine where to start. Determine priorities and appropriate Generate Solutions and expected outcomes with the use of mutual determine what you can do. goal setting. Identify appropriate 4 Plan interventions considering risks/benefits/alternatives Implement the agreed-upon individualized Take Action and determine 5 Implement interventions what you will do. Occurs throughout the nursing process Evaluate Outcomes and (dynamic feature). Reassessment of the determine did it help? 6 Evaluate response to the intervention(s). Requires revisiting the expected outcome. Remember to document: If it is not documented, it didn’t happen! Why do we need the nursing process? This process helps to diagnose and treat human responses (e.g., patient symptoms) to patient health problems. Nursing is a unique discipline and this process is a way for us to ‘think through patient clinical problems (Potter et al., 2023). What is NANDA? The North American Nursing Diagnosis Association (NANDA) is a professional organization of nurses interested in standardized nursing terminology. It was officially founded in 1982. It develops, researches, disseminates, and refines the nomenclature, criteria, and taxonomy of nursing diagnoses (Nursing Diagnosis Handbook 12th ed. found in your book bundle). Prior to  2 NANDA listings of approved diagnoses, nurses generally provided care according to the medical diagnoses. If nursing is to be recognized as an autonomous profession, it is necessary to have standardized vocabulary that reflects the nature and scope of nursing actions. Nurses treat the whole person, and do not just center on the disease process. Each patient is unique; therefore each nursing diagnosis takes into account the problem, the etiology (related to “R/T” or cause: the stressor), and the defining characteristics that the individual patient has (signs and symptoms or “as evidenced by” AEB: the patient’s stress response). Formulating a Nursing Care Plan: The elements of the nursing care plan include: 1. Cluster of related abnormal assessment data 2. Diagnostic Statement a. NANDA dx b. “Related to” R/T factor (etiology) c. “Secondary to” This can be used to help clarify the R/T factor d. “As evidenced by” AEB factor (defining characteristics) 3. Expected Outcome 4. Planned Interventions (Nursing Actions) 5. Evaluation I. Cluster Similar Assessment Data: After collecting the assessment data, consider, “What is abnormal? What is a cause of concern? What is the Stressor? What appears to be a problem area?” The best way to do this is to make a list of all the abnormal findings. Notice if there is a “cluster” of abnormal assessment data that all points to one direction. A Nursing Diagnosis is then formulated based on the cluster of data. The cluster of data is generally your AEB information. For example: the patient requires supplemental O2, the patient states “It’s so hard to breathe!” The RR is 28/minute, and the SaO2 is 92%: These all point to the diagnosis of Impaired Gas Exchange.  3 II. Nursing Diagnosis The term “diagnostic statement” is the full statement in the nursing diagnosis. It includes the following elements: Consider the most appropriate NANDA diagnosis (Nursing Diagnosis Handbook 12th ed) that addresses the problem. It is Nursing Diagnosis from the based on similar clustering of abnormal assessment findings. For NANDA example: Decreased cardiac output, Impaired physical mobility A patient’s response to a health problem related to a set of Related to factor (R/T) or conditions that caused or influenced the response. Related Etiology (cause) factors are etiologies, circumstances, facts, and influences that have a relationship with the nursing diagnosis. The medical diagnosis can support the nursing R/T factor written as: “secondary to” This phrase may be added to the etiology (R/T) to help clarify it, and commonly cites a medical condition. *Secondary to: For example: Decreased cardiac output R/T alteration in stroke volume secondary to congestive heart failure (the medical diagnosis). It simply gives the medical reason for the etiology. The defining characteristics are the evidence or the major assessment findings. They must be signs and symptoms that this patient exhibits. They are both objective and subjective signs. The defining characteristics are preceded by the term “as As Evidenced By (AEB) or evidenced by” (AEB). For example: Decreased cardiac output “defining characteristics R/T alteration in stroke volume secondary to congestive heart failure AEB cyanosis, crackles in lung fields, dyspnea, decreased ejection fraction (EF). * “Secondary to” may be added to the diagnosis for clarity but it is not essential.  4 Medical Diagnosis vs. Nursing Diagnosis Medical Diagnosis/Focus Nursing Diagnosis/Focus The identification of a disease Nursing treats the patient’s response to condition based on: their medical diagnosis; not the Specific evaluation of physical diagnosis: S&S Acute pain Patient’s medical history Education deficits Results of diagnostic Impaired skin integrity tests/procedures Impaired mobility Remains constant throughout Dynamic process based on illness patient needs For example: For a patient with a medical diagnosis of an appendectomy (removal of their appendix) nurses do not provide care due to the missing appendix. They provide care, in part, to prevent incisional infection, address acute pain, assess mobility, and monitor bowel sounds and nutrition. Examples of writing a diagnostic statement (Nursing Diagnosis): 1. Impaired physical mobility (the NANDA nursing diagnosis) R/T cerebral damage in the right side of the brain secondary to right CVA (medical diagnosis) AEB paralysis of the left side of the body (and any other subjective and objective cluster of data you might want to add). 2. Impaired gas exchange R/T constriction of airway secondary to asthma AEB wheezing, need for supplemental O2, and patient states “It’s so hard to breathe!” How would you prioritize the nursing diagnosis above? Why? There are three types of nursing diagnoses: Problem Focused Response to an existing condition in a patient, family, or community **Risk Diagnosis Response to conditions that may develop (i.e. falling). Health Promotion. Response to motivation and readiness for new knowledge. **Risk for –With “risk for” diagnosis no AEB is necessary as the problem hasn’t happened yet. The following R/T statements may be used when indicated: The cause or related stressor is unknown. R/T Unknown etiology Many varied and complex factors, listing all of them would be R/T Complex Factors cumbersome. Used when the relationship is suspected and/or uncertain R/T Possible  5 III. Expected Outcome: After the nursing diagnosis has been identified for the patient, the next step is the identification of an appropriate outcome. An expected outcome is a measurable change in the behavior or condition as a result of a specific intervention or action. Patient outcome criteria differ from goals. Goals are broad general statements that describe the desired change in behavior or status. An outcome is a specific measurable change that needs to be achieved to reach a goal of it like baby steps towards the overarching goal. Outcome criteria can easily be evaluated because they are so specific. The terms, at times, seem to be used interchangeably, however, there is a difference in their definition. Outcomes are SMART: S: Specific (also consider Singular) M: Measurable A: Attainable R: Realistic T: Time-specific Outcome criteria is conceptualized based on the nursing diagnosis. The nurse considers the problem of the patient, and with the patient, when possible, identifies the change(s) that is desired. It is most likely the opposite of the diagnosed problem. For example: If the diagnosis is Risk for Falls, then the most logical outcome would be “The patient will not fall throughout hospitalization”. For every nursing diagnosis there may be more than just one possible outcome. However, do not include more than one outcome expectation in the same outcome statement. Outcomes are written as singular although there may be multiple possibilities for an outcome. Consider the components of a patient outcome criterion: The subject is the patient and/or the descriptive elements of the patient problem. “Patient”, however, in the nursing paradigm may be an 1 SUBJECT individual, family, or community. The action verb that can be measurable. For example: “The patient will TASK state, describe, ambulate, demonstrate….” As opposed to: “The patient will 2 STATEMENT understand” as “understanding” is not measurable. The means by which the outcome is met. What is being evaluated? For example: walking a distance, reporting a pain scale, repeating back 3 CRITERIA teaching material, or VS measurements. Be certain the criteria is measurable. See example #2 below TIME The time frame in which the outcome is expected to be reached. 4 FRAME  6 Example Outcome-Correct: (for a nursing diagnosis of Acute Pain) The patient will report (action verb) their desired pain goal (specific) of 3 on a 1-10 scale (measurable) 1 hour (realistic and attainable) after pain medication administration (time specific). Example Outcome-Incorrect (not singular) The patient will report their desired pain goal of 3 on a 1-10 scale and participate in physical therapy (note these are 2 expectations) 1 hour after pain medication administration. Below are 2 examples of a nursing diagnosis with outcome criteria: 1. Diagnosis: Impaired skin integrity R/T continual bed rest AEB reddened coccyx area. Form the outcome by reversing the patient’s problem into a healthier condition. Outcome: Pt will maintain skin integrity during hospitalization. 2. Diagnosis: Impaired gas exchange R/T fluid in lungs secondary to pneumonia AEB confusion, increased respirations (24/ min), crackles in lung fields, and abnormal blood gases (pH 7.28). *In this case the medical diagnosis is included as a “secondary to” indicating why the patient has fluid in the lungs. Form the outcome by reversing the patient’s problem into a healthier condition. Outcome: Pt. will maintain adequate gas exchange throughout hospitalization AEB SpO2 greater than 92% (this outcome requires an AEB to make it measurable as “adequate” is not measurable). IV. Interventions (Nursing Actions) A nursing intervention is any direct care treatment that a nurse performs on behalf of the patient. There are three categories of nursing interventions: independent nursing actions (nurse driven or autonomous), dependent nursing actions (dependent on physician orders) or interdependent actions (performed in conjunction with other members of the health care team such as giving range of motion exercises which are also done by the Physical Therapist). *Before implementing any intervention, including MD orders, a quick reassessment is essential to determine if the intervention remains applicable to this patient at this specific time. Planned nursing interventions focus on eliminating or reducing the etiology (cause) of the patient’s problem(s). For instance, if a patient has constipation related to poor fiber intake, interventions may include: 1. Administer a prescribed laxative (dependent action) 2. Encourage fluids and activity and 3. Encourage a higher fiber diet. Unless the cause of the problem is addressed, it will continue to (re)occur despite measures to relieve the AEB factors. The Level 1 nursing care plans require 3 nursing interventions for each nursing diagnosis. Consider the consequences of each planned nursing intervention. Nursing interventions, or  7 actions, must reflect current nursing practice, be evidence-based, and covered within the policies of the institution and the scope of practice in nursing. Interventions may be taken from any evidence-based source including textbooks and guides for professional practice. The vast selection of approved Nursing Interventions Classification (NIC) found in the Nursing Diagnosis Handbook from your book bundle are common interventions recommended for various NANDA nursing diagnosis developed by the University of Iowa. Guidelines for Writing Nursing Interventions 1. Ask yourself, will these interventions help the patient achieve their outcome criteria and do they address the etiology? Do the diagnosis, outcome, and interventions flow? 2. Ensure all interventions are evidence-based, within the scope of nursing practice, within the capability of the caregiver, and within the capability of the recipient of care. *All interventions will include rationale and source for the Level 1 care plan (see the final care plan example at the end of this study packet). 3. Actions may be stated as “assess for” or “monitor” however, include more than just assessing or monitoring the patient. What will YOU do for the patient? 4. Avoid repeating doctor’s orders (dependent interventions), such as “give lasix”. However, state “observe urine response from Lasix”, or “monitor daily K+ reports”. 5. Don’t forget to include teaching and preventative actions. 6. It is possible to include other health team members in your plan such as “consult with dietician” (collaborative interventions) but be realistic. You will not be referring the patient to a psychiatrist as that is out of the scope of practice. 7. Individualize your interventions to your patient. Be certain the intervention you choose, which may be a great intervention, is appropriate to your particular patient. Include the patient and family whenever possible. Examples of Nursing Interventions Diagnosis: Impaired skin integrity R/T continual bed rest AEB reddened coccyx area. Outcome: Pt. will have an absence of redness to the coccyx within 24 hours. Interventions: (These are all examples of prudent interventions however you only need to include three) 1. Turn patient every 2 hrs. 2. Encourage pt to change position every 30 min. 3. Teach why it is necessary to move frequently.  8 4. Keep sheets free of moisture and wrinkles. 5. Keep skin clean from urine or feces. 6. Teach to do ankle pumps and stretches. 7. Offer liquids when entering room. 8. Teach need for adequate nutrition and liquids to present skin breakdown. 9. Place eggcrate mattress or air mattress on bed. 10. Assess for skin breakdown. During shift assessment and every time pt is turned. *Note: A short rationale and a cited source such as Potter & Perry or the Ackley, Ladwig texts, are required for each intervention for the level 1 nursing care plan. Example at the end of this study packet. V. Evaluation The last step of the nursing process as well as the nursing care plan is evaluation Evaluation is ongoing and dynamic. It is performed after each step of the nursing process. For the patient’s plan of care, the outcome criteria are used to evaluate whether (or not) the patient is making progress. Evaluation is also performed after each nursing intervention/action noting the patient’s response to care. When the outcome criteria are not met, or are partially met, it signals that something must be altered or something different must be done. The nurse must evaluate whether the nursing interventions were appropriate for the specific outcome, if they were accomplished as directed, or, perhaps, other interventions would be more appropriate. Also consider whether the expected outcome is attainable and realistic or that the correct nursing diagnosis was properly identified. All nursing actions and the patient’s response to care must be documented. This includes the positive responses as well as the unintended or unexpected responses. When possible, input from the patient, the family and other health care providers is obtained. Documenting Evaluation on the Plan of Care Generally, student nurses care for a patient briefly, on one day of a week for a set number of hours. It may be difficult to evaluate progress in such short span of time. However, even in that period it may be possible to see some positive or negative changes occur depending on the specified outcome and planned interventions. Nurses who work with patients consistently over longer periods of time are able to evaluate outcome criteria more easily. Evaluation of an intervention is, in essence, another nursing assessment; hence the dynamic feature of the nursing process (Ackley, Ladwig 12th ed., p.10). Documentation in the clinical setting is likely in an electronic format. Documentation of the physical assessment and responses to care are on-going and many times cross-linked to other  9 sections of the health care record for easy accessibility. The documentation mentioned here is specifically for the patient care plan. Generally, the following three outcome measures are documented for the nursing care plan: 1. Criteria met 2. Criteria unmet 3. Criteria partially met After one of these 3 phrases, state why. If the criterion was met, briefly describe the changes or actions of the patient that occurred based on the outcome criteria. For example: If the patient’s Oxygen stauration was projected to increase over 90%, write: Criteria met: O2 sat 95% If the criterion was unmet, describe why not. For example, if the criteria stated that the patient would meet their pain goal 1 hour after pain medication administration but the pain goal was not met, document: Criteria unmet: Pt’s pain continues at 7 on a scale of 0 – 10. Primary RN notified. If the criterion was partially met, describe what was met and what was not met, respectively.  10 References Ackley, B.J., Ladwig, G.B. & Flynn Makic, M.B. (2017). Nursing diagnosis handbook and evidence-based guide to planning care. (12th ed.). St. Louis, MO: Elsevier. Potter, P.A., Perry, A. G., Stockert, P.A., & Hall, A.M. (2023). Fundamentals of nursing (11th ed.). St. Louis, MO: Elsevier.  11 Critical Thinking Exercises. Case Scenario: This case scenario will be used in the workshop. Please read this in preparation for class and have it available for reference. Abby Linderman: THR Abby Linderman, is a 68-year-old widow who has been hospitalized for a fractured hip due to a mechanical fall. She had an open reduction and internal fixation (ORIF “hip replacement”) of her left hip two days ago. She has a 4-inch well-healing incision with steristrips to her left lateral thigh. She is normally active, and A&O x4 but since the surgical procedure she has been pleasantly confused and does not remember that she is in the hospital. She periodically attempts to get out of bed but has poor balance and strength due to the surgery. She moans with pain when repositioned. Last vital signs: Temp 99.8, pulse: 88, RR 24, BP: 140/76, O2 Sat 94% Hemoglobin is 8.9 (low). There is a moderate sized ecchymotic area around the lateral hip incision which is 3 inches long. There is a dressing on the incision some old dried blood showing through. She has a Foley catheter, which is draining clear, yellow urine. Her coccyx is reddened, does not blanch but there is no skin breakdown. Bowel sounds are hypoactive in all four quadrants. The last BM was 5 days ago. She is taking Percocet (opioid narcotic) every 6 hours ATC for pain. She is able to eat a soft diet with encouragement however, does not like to drink much. She has an IV of ¼ NS which is infusing at 70 cc hour without redness or edema at the site. She lives alone, but her neighbor tells you she has a dog that she loves dearly. Ms. Linderman occasionally asks where her dog is because she misses her so much. Ms. Linderman is retired and has Medicare health insurance. Example: Putting It All Together This is what a care plan will look like. 13 Cluster of Data Diagnostic Statement Expected Outcome Nursing Interventions Evaluation *A full reference page in APA format that includes the full citation of your resources will be required in your Care Packet.  Exam 3 Study Guide Chapter 41 Oxygenation Approx Q’s= 15 Chapter 48 Skin Approx Q’s= 15 Integrity/Wound Care Chapter 50 Periop Nursing Approx Q’s= 7 Care Chapter 44 Pain Management Approx Q’s= 8 Chapter 17,18,19,20 Nursing Approx Q’s= 15 Process Total Q’s= 60 Chapter 41 Oxygenation: 1. Oxygen delivery devices (Table 41.7) * Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider’s order* What device do we start with? The nasal cannula and oxygen masks are most common devices to deliver oxygen to patients Nasal Cannula: has two nasal prongs slightly curved and inserted in patient’s nostrils Assess patients for skin breakdown over the ears and in the nostrils Flow rates equal or greater than 4 L/min have drying effect on the mucosa (needs to be humidified) Oxygen Mask: a plastic device that fits snugly over mouth and nose, is secured in place with strap. Two primary types of oxygen masks: delivering low concentrations of oxygen and delivering high concentrations. 1. Simple Face Mask - for short-term oxygen therapy contraindicated for patients with carbon dioxide retention because retention can be worsened, leading to decreased levels of consciousness 2. Partial rebreather & non rebreather masks - simple masks with reservoir bag that are capable of delivering higher concentrations of oxygen for short period of time Frequently inspect reservoir bag to make sure it’s inflated, If deflated, patient is breathing large amounts of exhaled carbon dioxide 3. Venturi mask - high-flow, more precise oxygen concentrations Usually reserved for COPD pts who need low, constant oxygen concentrations What do we do in emergencies? During cardiac arrest there is an absence of pulse and respiration, requires CPR Cardiopulmonary resuscitation (CPR): a basic emergency procedure of artificial respiration and manual external cardiac massage sequence for CPR is C-A-B: chest compression, early defibrillation, establishing an airway, and rescue breathing Adequate compressions in adults need to occur at a rate of 100 to 120/minute with a depth of at least 2 inches and allow for full chest recoil between compressions If artificial airway → ventilate one breath every 6 seconds (10/minute) If no artificial airway (e.g., endotracheal/tracheal tube) → maintain a 30:2 compression- ventilation ratio Defibrillation: When patient has shockable rhythm (ventricular fibrillation) delivers electrical current to myocardium that stops electrical activity and allows heart’s normal pacemaker to resume normal activity recommended that defibrillation occur within 5 minutes for an out-of-hospital sudden cardiac arrest and within 3 minutes for a patient in a hospital 2. Angina vs MI Angina: Imbalance between myocardial oxygen supply and demand. ➔ Results in aching, sharp, tingling, burning, or pressure ➔ Chest pain is left sided or substernal and often radiates to the left or both arms, the jaw, neck, and back. (Some patients pain does not radiate) ➔ It usually lasts from 3 to 5 minutes ➔ Often precipitated by activities that increase myocardial oxygen demand (e.g., eating heavy meals, exercise, or stress) ➔ Usually relieved with rest and coronary vasodilators, the most common being a nitroglycerin preparation In women: different symptoms or no symptoms at all. typical symptoms, such as palpitations, anxiety, weakness, and fatigue. will have ischemia noted on electrocardiogram, but no evidence of coronary artery disease MI: (Myocardial infarction) or acute coronary syndrome (ACS) results from sudden decreases in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion Occurs because ischemia is not reversed Cellular death occurs after 20 minutes of myocardial ischemia Rest, position change, or sublingual nitroglycerin administration does not relieve the pain In men: described as crushing, squeezing, or stabbing. The pain is often in the left chest and sternal area - May be felt in the back; and radiates down the left arm to the neck, jaws, teeth, epigastric area, and back - Occurs at rest or exertion and lasts more than 20 minutes In women: As women get older, their risk of heart disease begins to rise, making it the leading cause of death for women in the United States - Women on average have greater blood cholesterol and triglyceride levels than men - Obesity more prevalent, increases risk for diabetes and cardiac disease - Most common initial symptom in women is angina, but they also present with atypical symptoms such as fatigue, indigestion, shortness of breath, and back or jaw pain - Women have twice the risk of dying within the first year after a heart attack than men 3. Factors influencing oxygenation, including Table 41.1  4. Alterations in respiratory functioning and cardiac functioning Alterations in respiratory functioning: Hypoventilation: occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or to eliminate sufficient carbon dioxide. As alveolar ventilation decreases → body retains carbon dioxide In COPD patients, administration of excessive oxygen → hypoventilation - These patients adapted to a high CO2 level - Their peripheral chemoreceptors of the aortic arch and carotid bodies are primarily sensitive to lower oxygen levels → increased ventilation - resulting hypoventilation cause excess retention of CO2 → respiratory acidosis and respiratory arrest Signs/symptoms: mental status changes, dysrhythmias, potential cardiac arrest Hyperventilation: a state of ventilation where lungs remove carbon dioxide faster than produced Causes: Severe anxiety, infection, drugs, or acid-base imbalance - Acute anxiety - exhalation of excessive amounts of carbon dioxide - Infection - Increased body temp increases metabolic rate → increasing CO2 → stimulates increase in patient’s rate and depth of respiration Sometimes chemically induced  - For ex. salicylate (aspirin) poisoning and amphetamine use → excess CO2, stimulating respiratory center to compensate by increasing the rate and depth of respiration - When body tries to compensate for metabolic acidosis Symptoms: rapid respirations, sighing breaths, numbness and tingling of hands/feet, light-headedness, and loss of consciousness Alterations in cardiac functioning Disturbances in conduction: cause by Electrical impulses that do not originate from SA node 1. Dysrhythmia - a deviation from the normal sinus heart rhythm Atrial fibrillation - electrical impulse in atria originates from multiple sites - Rhythm irregular because of multiple pacemaker sites and unpredictable conduction to ventricles - QRS complex is normal but occurs at irregular intervals - Decreases cardiac output by altering preload and contractility Ventricular dysrhythmias - represent ectopic site of impulse formation within ventricles - impulse originates in ventricle, not SA node - QRS complex is widened and bizarre (P waves not always present, they are buried in the QRS complex - Ventricular tachycardia: life-threatening dysrhythmia because of decreased cardiac output and potential to deteriorate into ventricular fibrillation (sudden cardiac death) 5. Responsibility of alveoli Nursing action to prevent complications (don’t forget mobility) Alveoli: essential for exchange of respiratory gases, oxygen and carbon dioxide (CO2), are exchanged Process of oxygenation: ventilation, perfusion, and diffusion 1. Ventilation - process of moving gases in and out of lungs, with air flowing into lungs during inhalation and out of the lungs during exhalation 2. Perfusion - ability of cardiovascular system to pump oxygenated blood to tissues and return deoxygenated blood to lungs 3. Diffusion - moving respiratory gases from 1 area to another by concentration gradients Atelectasis - collapse of the alveoli - Surfactant: chemical produced in the lungs to maintain surface tension of alveoli and prevent them from collapsing Residual Volume - the amount of air left in the alveoli after full expiration Nursing Interventions: 1. Position head of bed elevated 30-45 degrees or sit in chair Increases depth and lung expansion, reduces airway resistance 2. Ambulate in room or hall at least 2x a day Early mobilization prevents muscle weakness, facilitates removal of secretions 3. Deep breath and cough Helps remove sputum, promotes gas exchange 4. Increase fluid intake to at least 2500 mL/daily Helps liquify airway secretions 5. Avoid caffeinated beverages and alcohol Caffeinated and alcoholic beverages promote diuresis and dehydration 6. Hypoxia- Clinical manifestations (signs and symptoms) Hypoxia: inadequate tissue oxygenation at cellular level.Results from deficiency in oxygen delivery or oxygen use in cells. (Untreated → fatal cardiac dysrhythmias) 1. Causes: a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood diminished concentration of inspired oxygen, occurs at high altitudes inability of the tissues to extract oxygen from the blood (i.e cyanide poisoning) decreased diffusion of oxygen from the alveoli to the blood (i.e pneumonia or pulmonary edema) poor tissue perfusion with oxygenated blood (i.e shock) impaired ventilation (i.e. multiple rib fractures or chest trauma) 2. Signs & symptoms Early stages: blood pressure is elevated unless condition is caused by shock - apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes unable to lie flat and appears both fatigued and agitated Vital sign changes include an increased pulse rate and increased rate and depth of respiration Later stages: respiratory rate declines as a result of respiratory muscle fatigue 7. Right vs Left-sided Heart Failure Clinical manifestations of R vs L heart failure ➔ Left-sided HF: decrease amount of blood ejected from left ventricle = decreasing cardiac output Pumps oxygenated blood from the lungs to the rest of the body.  S&S: fatigue, breathlessness, dizziness, and confusion - prolonged symptoms may lead to pulmonary congestion that may lead to symptoms such as: crackles, hypoxia, SOB, paroxysmal nocturnal dyspnea. ➔ Right-side HF: decrease amount of blood ejected from right ventricle; long term effect of L. side HF Pumps deoxygenated blood from the body to the lungs. S&S: weight gain, distended neck veins, hepato/splenomegaly, and peripheral edema. 8. Dangers of Carbon Monoxide (Decreased oxygen-carrying capacity) Carbon monoxide (CO): colorless, odorless gas that causes decreased oxygen-carrying capacity of blood In CO toxicity, hemoglobin strongly binds with CO → functional anemia CO does not easily dissociate from hemoglobin → making hemoglobin unavailable for oxygen transport People with CO poisoning often unaware of their exposure to this gas Symptoms: headache, dizziness, nausea, vomiting, & dyspnea (mimics other illnesses) - Patients will have vague complaints of general malaise, flu like symptoms, and excessive sleepiness. Causes: often from improperly vented furnace flue or fireplace Decreased oxygen-carrying capacity: Hemoglobin carries majority of oxygen to tissues Anemia and inhalation of toxic substances decrease the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen - Anemia: a result of decreased hemoglobin production, increased red blood cell destruction, and/or blood loss - Oxygenation decreases as a secondary effect with anemia The physiological response to chronic hypoxemia is the development of increased red blood cells (polycythemia) - This is the adaptive response of the body to increase the amount of hemoglobin and the available oxygen-binding sites 9. Tasks that can be delegated when applying oxygen (Box 41.9) Applying a nasal cannula or oxygen mask after the method of delivery and percentage of oxygen needed by a patient is determined Safely adjust the device (e.g., loosening the strap on the oxygen cannula or mask) and clarify its correct placement and positioning.  Inform the nurse immediately about any changes in vital signs; changes in pulse oximetry (SpO2); changes in level of consciousness (LOC); skin irritation from the cannula, mask, or straps; or patient complaints of pain or shortness of breath. Provide extra skin care around patient's ears and nose 10. Different coughing and deep breathing techniques Coughing: effective technique for maintaining patent airway. Deep-breathing exercise with coughing is an airway clearance maneuver that is effective when spontaneous coughing is inadequate removes secretions from airways normal series of events: deep inhalation, closure of the glottis, active contraction of the expiratory muscles, and glottis opening - Deep inhalation: increases lung volume & airway diameter → allows air to pass through obstructions - Contraction of the expiratory muscles against closed glottis → high intrathoracic pressure to develop - When glottis opens → large flow of air is expelled at high speed, provides momentum for mucus to move to upper airways → allows to expectorate/swallow 1. Huff cough: stimulates natural cough reflex, used to move secretions to larger airways patient inhales deeply, holds breath for 2 - 3 seconds While forcefully exhaling, patient opens glottis by saying”huff” When using a cascade cough, patient takes slow, deep breaths, holds it for 1 to 2 secs, then performs series of coughs during exhalation - often used in patients with large amounts of sputum, (ex. cystic fibrosis) 2. Quad Cough: manually assisted cough technique for patients without abdominal muscle control (ex. with spinal cord injuries) While patient breathes out with a maximal expiratory effort, patient or nurse pushes inward and upward on the abdominal muscles toward diaphragm Deep Breathing Technique 1. Pursed Lip Breathing: involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse Instruct patient (while sitting up) to take a deep breath and exhale slowly through pursed lips (blowing out candle) counting inhalation time and gradually increasing count during exhalation What is it used for: to gain control of the exhalation phase so it’s longer than inhalation, to improve exercise tolerance in patients with COPD What do they prevent: alveolar collapse  2. Diaphragmatic Breathing: increases tidal volume and decreases respiratory rate Steps: place one hand below the breastbone (upper hand) and the other hand (lower hand) flat on the abdomen, ask the patient to inhale slowly (making abdomen push out) and move the lower hand outward. When patient exhales, abdomen goes in (the diaphragm ascends and pushes on lungs to help expel trapped air) Requires patient to relax intercostal & accessory respiratory muscles while taking deep inspirations Often used with the pursed-lip breathing technique What is it used for: useful for patients with pulmonary disease and dyspnea secondary to heart failure, increases the patient’s tidal volume and oxygen saturation, reduces dyspnea, and improves exchange of respiratory gases What does it prevent: Leads to overall improved breathing pattern & quality of life 11. Nursing implications for O2 administration for COPD patients COPD patients have a higher CO2 level than O2 levels Signs: Use of accessory muscles, increased WOB, increased need for O2 Nurses should be careful in the amount of O2 being administered, high CO2 levels - Venturi mask delivers precise O2 concentrations (typically used for COPD) - Pursed lip-breathing and diaphragmatic breathing methods help - Spontaneous pneumothorax (collapsed lung → air leaks into pleural cavity) 12. Mobility and oxygenation (Table 41.6 positions for postural drainage)  13. Health promotion to prevent respiratory infections Healthy Lifestyle: Implementations for Cardiac Disease - Healthy low fat, high fiber diet - Maintain healthy BMI - Maintain good exercise (150 min a week), healthy stress levels Humidification: process of adding water to gas to keep air moist Nebulization: adds moisture to inspired air by mixing particles of varying size with air Enhances secretion removal Chest physiotherapy (CPT): external chest wall manipulation using percussion, vibration, compression Manual chest percussion: rhythmically clapping (cupped hand) on chest wall over area to force secretion into larger airways - Should produce hollow sounds High frequency chest wall compression: inflatable vest attached to air pulse generator - Delivers high frequency vibrations to remove secretions Positive Expiratory Pressure (PEP): allows air to be inhaled easily But forces exhalation with resistance Allows air get behind mucus Incentive Spirometry: encourages deep breathing with visual feedback Thought to prevent atelectasis  1. Flow-orientated: has 1 or more plastic chambers that contain balls, patient has to keep them floating 2. Volume-orientated: has bellows and achievement light that turns on when patient reaches desired volume Chapter 48 Skin Integrity/Skin Wound: table 48.5 Braden Scale- Braden Scale for Predicting Pressure Ulcer Risk (Fig 48.9- bony prominences)  1. Types of tissue (granulation, slough, eschar) Granulation: red, moist tissue composed of new blood vessels - the presence indicates progression toward healing Slough: Soft yellow/white stringy substance attached to wound bed - must be removed HCP or by appropriate wound dressing before wound can heal Eschar: Black, brown, tan, or necrotic tissue 2. which also needs to be removed before healing can occur 2. Nursing action for prevention of pressure injuries (table 48.1 strategies to prevent medical and immobilization device-related pressure injuries, table 48.8 quick guide)  3. Pathogenesis for pressure injury development (and Box 48.1 skin associated issues) Pathogenesis of pressure injuries: Pressure interferes with blood flow → interfere with cellular metabolism and life of cells → tissue ischemia and tissue death Risk Factors: - Impaired sensory perception - Impaired mobility - Alteration of LOC: may not be able to communicate/understand their discomfort - Shear: sliding movement of skin which underlying muscle and bone is still, underlying tissue capillaries are stretched → necrosis deep in tissue layers (affects dermis) - Friction: (affects epidermis) occurs with uncontrollable movements  - Moisture: reduces resistance of skin to other factors Classifications - Stage 1: intact with nonblanchable erythema - Stage 2: Partial thickness loss with exposed dermis - Stage 3: Full thickness loss, adipose tissue is visible (may have slough or echar) - Stage 4: Full thickness loss with exposed muscle, tendon, ligament, cartilage, bone - Unstageable: Full thickness skin and tissue loss but cant see (slough or eschar) - Deep tissue PI: Persistent nonblanchable deep red, maroon, or purple under skin 4. Types of wound drainage (Table 48.3) 5. Nursing action for an eviscerated wound Evisceration: Visceral organs protrude through wound opening *an emergency that requires surgical repair* place sterile gauze soaked in sterile saline over extruding tissues to reduce chances of bacterial invasion and drying of the tissues Contact the surgical team - do not allow the patient anything by mouth (NPO) - observe for signs and symptoms of shock Prepare the patient for emergency surgery 6. Nutrition required for wound healing (Table 48.6 Role of selected nutrients in wound healing) – don’t forget about what you’ve learned from nutrition. 7. Delegation of skin/wound care (skill 48.1- yellow pages/back of chapter) Frequently change the patient's position, and use specific positions individualized for the patient.  Keep patient’s skin dry and provide hygiene following fecal or urinary incontinence or exposure of skin to wound drainage. Report any changes in the patient's skin, such as redness or break in the patient’s skin. Report any redness and/or abrasion from medical devices. Chapter 50 Perioperative Nursing Care: 1. Stages of surgery (periop, intraop, postop- what is the importance of each?) - Osmosis videos/class discussion. Perioperative: Goal is to consider what is normal for planned surgical procedures, including anticipated effects on body Recognize surgical risks and complications Create relationship with patient to collaborate for the patient needs and expectations Review patients medications (determine if it may increase risk of complications) Prepare patient for surgery Stages 1. Prior to admin of anesthesia 2. Prior to skin incision 3. Prior to patient leaving operative area Intraoperative: Takes care of patient during surgery Nursing roles 1. Circulating Nurse: does not scrub in, manages patient care actvities in OR (position, skin prep, meds, warming devices, specimens) 2. Scrub Nurse: anticipates each instruments for the surgeon and supplies Gets SBAR from preop nurse Postoperative: Take care of patient from recovering from anesthesia to discharge 1. Phase 1 (Immediate postop recovery) Close monitoring required Assess after effects of anesthesia 2. Phase 2 (early postop) Plans to progress patient home 3. Phase 3 (convalescent) Focus on providing ongoing care for patients who need extended observation or intervention after first 2 phases  2. Surgical risk factors (know what they are and why they put your client at risk, table 50.3 Physiological factors that place the older adult at risk during surgery, table 50.4 Medical conditions that increase risks of surgery) ➔ Factors that older adult at risk during surgery: (Table 50.3) System Alterations Risks Nursing Implication Cardiovascular Degenerative change in Decreased cardiac Assess baseline vital signs myocardium and valves reserve puts older adults for tachycardia, fatigue, at risk for decreased and arrhythmias. A cardiac output, especially complete, comprehensive during times of stress cardiac workup according to agency policy should be completed before surgery. Rigidity of arterial walls and Alterations predispose Maintain adequate fluid reduction in sympathetic patient to postoperative balance to minimize and parasympathetic hemorrhage and rise in stress to the heart. innervation to the heart systolic and diastolic Ensure that blood blood pressure pressure level is adequate to meet circulatory demands. Increased calcium and Alterations predispose Instruct patients in cholesterol deposits within patient to postoperative techniques of leg small arteries; thickened hemorrhage and rise in exercises and proper arterial wall systolic and diastolic turning. Apply elastic blood pressure stockings or intermittent pneumatic compression (IPC) devices. Administer anticoagulants as ordered by the health care provider. Provide education regarding effects, side effects, and dietary considerations. Integumentary Decreased subcutaneous Prone to pressure Select the appropriate tissue and increased injuries and skin tears surface for the OR table. fragility of skin Assess skin every 4 hours; pad all bony prominences during surgery. Turn or reposition at least every 2 hours. Pulmonary Decreased respiratory Increased risk for Assess risk factors for muscle strength and cough atelectasis postoperative pulmonary reflex complications. Instruct patients in proper technique for coughing, deep breathing, and use of a spirometer. Ensure adequate pain control to allow for participation in exercises. Reduced range of Residual capacity When possible, have movement in diaphragm (volume of air left in lung patients ambulate and sit after normal breath) in chairs frequently. increased, reducing amount of new air brought into lungs with each inspiration Stiffened lung tissue and Blood oxygenation Obtain baseline oxygen enlarged air spaces reduced saturation; measure throughout perioperative period. GI Gastric emptying delayed & Increases risk for reflux Assess nutritional status saliva production decreased and indigestion and and implement constipation preventive measures in high-risk patients. Position patient with head of bed elevated at least 45 degrees. Reduce the size of meals in accordance with an ordered diet. Renal Decreased renal function, Increased risk of shock For patients hospitalized with reduced blood flow to when blood loss occurs; before surgery, kidneys increased risk for fluid determine baseline and electrolyte urinary output for 24 imbalance hours. Reduced glomerular Limited ability to Assess for adverse filtration rate and excretory eliminate drugs or toxic response to drugs. times substances Reduced bladder capacity Increased risk for Instruct patient to notify urgency, incontinence, nurse immediately when and urinary tract sensation of bladder  infections. Increased risk fullness develops. Keep for postoperative urinary nurse call system and retention bedpan within easy reach. Toilet every 2 hours or more frequently if indicated. Neurology Sensory losses, including Decreased ability to Inspect bony reduced tactile sense and respond to early warning prominences for signs of increased pain tolerance signs of surgical pressure that patient is complications unable to sense. Orient patient to surrounding environment. Observe for nonverbal signs of pain. Febrile response during Increased risk of Ensure careful, close surgery undiagnosed infection monitoring of patient and hypothermia temperature; provide warm blankets; monitor heart function; warm intravenous fluids. Goals are to prevent heat loss. Maintain normothermia intraoperatively Decreased reaction time Confusion and delirium Allow adequate time to after anesthesia; respond, process increased risk for falls information, and perform tasks. Perform fall-risk screening and institute fall precautions. Screen for delirium with validated tools. Orient frequently to reality and surroundings. Metabolic Lower basal metabolic rate Reduced total oxygen Ensure adequate consumption nutritional intake when diet is resumed but avoid intake of excess calories. Reduced number of red Reduced ability to carry Administer necessary blood cells and hemoglobin adequate oxygen to blood products as levels tissues needed. Monitor blood test results and oxygen saturation. Change in total amounts of Greater risk for fluid or Monitor electrolyte levels  body potassium and water electrolyte imbalance and supplement as volume necessary. Provide cardiac monitoring (telemetry) as needed. ➔ Medical conditions that increase risks of surgery: (Table 50.4) 3. Nursing actions to prevent postoperative complications (and table 50.8 Postoperative complications) Nursing Actions: Monitor vital signs (based on hospital policy) usually every 15 mins twice, then every 30 mins twice, then every 2 hrs, then every 4 hrs Assess and maintain pt airway: Use incentive spirometer, controlled coughing Assess circulation: Early mobilization protocol, check circulation around surgical site Temp control: Offer blankets Assess neurological status: Help orient them Assess skin integrity and surgical wounds: frequent check for drainage, keep clean from infection Assess GI function: Administer laxatives as ordered, Follow diet (especially before peristalsis returns) Complication Cause Respiratory System Atelectasis Inadequate lung expansion. Anesthesia, analgesia, and immobilized position prevent full lung expansion. Greater risk in patients with upper abdominal surgery who have pain during inspiration and repress deep breathing Pneumonia Retained secretions or aspirated secretions. Common bacterium is Diplococcus pneumoniae Hypoxemia Anesthetics depress respirations. Increased retention of mucus with impaired ventilation occurs because of pain or poor positioning. Patients with obstructive sleep apnea are at increased risk for hypoxemia Pulmonary Embolism Because of immobile during surgery Circulatory Hemorrhage Dislodged clot or ripped suture. Patients with coagulation disorder at risk Hypovolemic Shock Caused by hemorrhage Thrombus Formation and Thrombophlebitis Prolonged immobilization, vessel trauma, and venous stasis Musculoskeletal Hospital Associated Deconditioning (HAD) Prolonged immobility can put decline on muscle strength and mass, reduced cognitive GI system Paralytic Ileus Anesthesia leads to loss of peristalsis Abdominal Distention Slowed peristalsis, bowel manipulation, air in stomach Nausea and vomiting Fear, abdominal distention, eating/drinking before peristalsis return Nervous System Intractable Pain: pain that cannot be relieved by analgesics or Related to wound and dressing, anxiety, positioning interventions Malignant hyperthermia Sever hypermetabolic state and rigid Genetic condition triggered by analgesic agents skeletal muscles 4. Purpose of Time-out procedure The three principles of protocol: ○ A preoperative verifications of the documents (consent, allergies, medical hx, and physical assessments)  ○ Marking the operative site with indelible ink to mark left and right distinction If the patient refuses a mark, document this on the procedure checklist. ○ Time-out: just before starting the procedure for final verification of the correct patient, procedure, site, and any implant. Most commonly occur in the holding area, just before the patient enters the OR 5. Never Events: A serious adverse event that occurs within a hospital and that is usually preventable No longer pays for the costs associated with “never events,” including treatment and hospital days associated with the event. Never events example is: DVT after total knee and hip surgery ○ A reduction in wound infection rates occurs when an antibiotic is administered 60 minutes before the surgical incision is made and the antibiotics are stopped within 24 hours after surgery. 6. Delegation of surgical care (skill 50.1 yellow pages/back of chapter) Nursing instructs AP: *Skills of preoperative teaching cannot be delegated to assistive personnel (AP)* Any precautions or safety issues unique to the patient (e.g., fall risks, mobility limitations, bleeding precautions). Informing the nurse of any identified concerns (e.g., inability to perform exercise). The Nursing Process (go back to module week 1/2 of canvas- use the ‘care plan workshop study packet’ as an additional helpful resource- this has chapters 15, 17,18,19,20 in a condensed form). 1. The nursing process and its relation to Clinical judgment 2. The parts of a nursing diagnosis (there are 3)  3. Creating a diagnosis from assessment (cluster) data 4. Purpose of a nursing diagnosis 5. What is data cluster? 6. What is a defining characteristic? 7. What is etiology? 8. Goal versus outcome 9. Collaborative vs independent vs dependent interventions 10. Order of the nursing process (know old version and new version- what are the questions you ask?) **many questions will be patient scenarios** **From the info given you will need to determine: 1) what is the best diagnosis, or 2) what will be the best intervention, or 3) how will you evaluate the effectiveness** Chapter 44 Pain Management: 1. PQRST and OLD CARTS ➔ PQRST: 1. Palliative or Provocative factors: What makes your pain worse? What makes it better? 2. Quality: Describe your pain for me. 3. Relief measures: What do you take at home to gain pain relief? What makes your pain go away?  4. Region (location): Show me where you hurt. 5. Severity: On a scale of 0 to 10, how bad is your pain now? What is the worst pain you have had in the past 24 hours? What is the average pain you have had in the past 24 hours? 6. Timing: Do you have pain all of the time, only at certain times, or only on certain days? 7. Understanding: Effect of pain: Describe what you cannot do because of your pain. With whom do you live, and how do they help you when you have pain? 2. Biases and misconceptions of pain (Box 44.2 and table 44.4- save table 44.3 for peds) ➔ Common biases and misconceptions about pain: (Box 44.2) The following statements are false: ○ Patients who abuse substances (e.g., use drugs or alcohol) overreact to discomfort. ○ Patients with minor illnesses have less pain than those with severe physical alteration. ○ Administering analgesics regularly leads to drug addiction. ○ The amount of tissue damage in an injury accurately indicates pain intensity. ○ Health care personnel are the best authorities on the nature of a patient’s pain. ○ Psychogenic pain is not real. ○ Chronic pain is psychological. ○ Patients who are hospitalized experience pain. ○ Patients who cannot speak do not feel pain. ➔ Misconception about pain in older adults: (Table 44.4) 3. Side effects of opioids (box 44.13) ➔ Common Opioid Side Effects: (Box 44.13) 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 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” 4. Non-pharmacological pain management methods Relaxation Distraction Music Cutaneous stimulation: massage, warm bath, cold compress, transcutaneous electrical nerve stimulation (TENS), acupuncture 5. Cultural influences on pain/pain perceptions (Box 44.4) 6. Prioritizing a patient in pain (ABC’s, pain, safety) a. Airway b. Breathing c. Circulation d. Pain e. Safety 7. Purpose of PCA (box 44.17) What is a Patient-controlled analgesia (PCA)? ○ It is a drug delivery system that allows patients to self-administer opioids (usually morphine, hydromorphone, or fentanyl) with minimal risk of overdose. ○ The goal is to maintain a constant plasma level of analgesic to avoid the problems of prn dosing. ➔ Purpose of PCA: (Patient teaching) (box 44.17) The patient gains control over pain, and pain relief does not depend on nurse availability. Patients also have access to medication when they need it.  Delegatable activities to a NAP regarding PCA use (skill 44.1, yellow pages/back of chapter) ➔ The skill of PCA administration cannot be delegated to assistive personnel (AP). The nurse directs the AP to: Notify the nurse if the patient expresses a change in status (e.g., unrelieved pain) or has difficulty awakening. Notify the nurse if the patient has questions about the PCA process or equipment. Never administer a PCA dose for the patient and to notify the nurse if anyone other than the patient is observed administering a dose for the patient. 8. Barriers to effective pain management (box 44.19) ➔ Patient barriers Fear of distracting health care Fear of addiction providers from treating illness Worry about side effects Believes health care providers Fear of tolerance (will not be have more important or sicker there when I need it) patients to see Takes too many pills already ➔ Health care provider barriers Concern about not being a Inadequate pain-assessment “good” patient skills Does not want to worry family No pain-management protocols and friends available May need more tests Concern with addiction or Suffering in silence is expected accidental overdose and needs to suffer to be cured Concern with co-morbid mental Inadequate education health conditions Reluctance to discuss pain Opiophobia, fear of opioids Belief that pain is inevitable Fear of legal repercussions Belief that pain is a part of aging Patient shows no visible cause Fear of disease progression of pain Believes health care providers Belief that patients need to learn and nurses are doing all they to live with pain can Reluctance to deal with side Forgets to take analgesics effects of analgesics  Not believing patient’s report of Difficulty in filling prescriptions pain Limitation on reimbursement for Fear that giving a dose will kill prescriptions patient Mail-order pharmacy restrictions Time constraints Advanced practice nurses not Inadequate reimbursement used efficiently Belief that opioids “mask” Poor pain policies and symptoms procedures regarding pain Belief that pain is part of aging management Overestimation of rates of Inadequate access to pain respiratory depression clinics ➔ Health care system barriers Poor understanding of economic Concern with creating “addicts” impact of unrelieved pain 9. Chronic vs acute pain ➔ Acute pain: Short duration, and has limited tissue damage and emotional response. It eventually resolves, with or without treatment, after an injured area heals. It is self-limiting because acute pain has a predictable ending (healing) and an identifiable cause, health team members are usually willing to treat it aggressively, and patients understand that their pain will eventually go away. ➔ Chronic pain: It is prolonged, varies in intensity, and usually lasts longer than 3 to 6 months and beyond the expected or predicted healing time Chronic pain does not always have an identifiable cause. Chronic pain is a major cause of psychological and physical disability, leading to problems such as job loss, inability to perform simple daily activities, sexual dysfunction, and social isolation.