MS_Prelims.pdf

 Stresses can be:  External (from the environment, psychological, or social situations)...

 Stresses can be:  External (from the environment, psychological, or social situations)  Internal (illness, or from a medical procedure).  Dr. Hans Selye  “a state of psychological and Lesson 1: Homeostasis, Stress and Adaptation physiological imbalance resulting from the disparity between situational demand and the individual's ability and motivation to meet those needs.” Let's look at the case of Norberto to guide our Adaptation discussion.  Adjustment to the stress or change so that the person is again in equilibrium and has the energy and ability to meet new demands.  It is a constant, on-going process that requires a change in structure, function, or behavior so that the person is better suited to the environment; it involves an interaction between the person and the environment  Coping Response  When person is in a threatening situation immediate response occur those response are often involuntary.  Adaptation  The change that takes place as a result STRESS AND FUNCTION of the responses to a stressor. STEADY STATE  A dynamic balance which is produced so Coping that all subsystems are in harmony with one  The process of adaptation another  A compensatory process with physiologic  The goal of the interaction of all body and psychological components. systems  Four concepts: constancy, homeostasis, stress, and adaptation Stress  State produced by a change in the environment that is perceived as STRESSORS challenging, threatening, or damaging to the  Stimulus that evokes stress person’s dynamic balance or equilibrium  An internal or external event or situation that creates the potential for physiologic,  Medical or biological context emotional, cognitive, or behavioral changes  Stress is a physical, mental, or in an individual emotional factor that causes bodily or mental tension. 1 CLASSIFICATION OF STRESSORS  One that is challenging, in that some o According to nature of stressor opportunity or gain is anticipated.  Physical: cold, health and chemical agents  Secondary appraisal  Physiologic: pain and fatigue  an evaluation of what might and can  Psychosocial: fear of failing an be done about the event examination and losing a job  Actions include assigning blame to those responsible for a frustrating o According to scope event, thinking about whether one can  Day-to-day frustrations or hassles: do something about the situation common occurrences as getting caught in (coping potential), and determining a traffic jam, experiencing computer future expectancy, or whether things downtime, and having an argument with a are likely to change for better or spouse or roommate worse.  Major complex occurrences involving large groups, even entire nations:  Reappraisal events in history, demographic, economic,  Change of opinion based on new and technological changes occurring in information society  Stressors that occur less frequently NOTE: The appraisal process results to the and involve fewer people: concerns development of emotions (either positive or relatively infrequent situations that directly negative) which can influence a person’s actions affect the individual, such as deaths, birth, towards the event marriage, divorce, retirement. o According to duration  Acute, time-limited stressor: such as studying for final examinations  Stressor sequence: a series of stressful events that result from an initial event such as job loss or divorce  Chronic intermittent stressor: such as 2. Coping daily hassles  Consists of the cognitive and behavioral  Chronic enduring stressor: one that efforts made to manage the specific persists over time, such as chronic illness, external or internal demands that tax a a disability, or poverty person’s resources  Done in response to a stressful situation RESPONSES TO STRESS  Emotion-focused coping  seeks to make the person feel better PSYCHOLOGICAL RESPONSES TO STRESS by lessening the emotional distress 1. Cognitive Appraisal felt  Primary appraisal  Problem-focused coping  An event is evaluated with respect to what  aims to make direct changes in the is at stake environment so that the situation can  What is at stake depends on personal be managed more effectively. goals, commitments, or motivations.  The outcome of primary appraisal is identification whether the event is stressful or not.  If non-stressful: the situation is irrelevant or benign (positive).  If stressful, situation may be one of three PHYSIOLOGIC RESPONSES TO STRESS o A protective and adaptive mechanism to kinds:  One in which harm or loss has maintain the homeostatic balance of the occurred; body.  One that is threatening, in that harm or loss is anticipated; 2   Stress response  being looked upon as a failure of the  a cascade of neural and hormonal normal process of adaptation to the events that have short- and long- stress lasting consequences for both brain and body. a o General Adaptation Syndrome (GAS)  Stressor  Hans Selye, 1936  an event that challenges  Three phases: Alarm, Resistance, homeostasis Exhaustion  Disease outcome THREE PHASES OF GENERAL ADAPTATION SYNDROME (GAS) ALARM RESISTANCE EXHAUSTION Release of catecholamines (epinephrine, norepinephrine) Hormonal Cortisol activity still and the onset of the Increased endocrine activity characteristics increased adrenocorticotropic hormone (ACTH)–adrenal cortical response SNS: “fight or flight”; adaptation to Due to prolonged exposure to defensive Characteristic the noxious stressor stressor and anti-inflammatory but occurs Depletion of body resources self-limited Physiologic Sustained SNS Harmful effects on body SNS stimulation effects response systems  If the local injury is severe enough, the general adaptation syndrome is activated as well. o Stress is the nonspecific response common to all stressors, regardless of whether they o Local Adaptation Syndrome (LAS) are physiologic, psychological, or social  Includes the inflammatory response and o Conditioning factors determine one’s repair processes that occur at the local tolerance or vulnerability to stress. site of tissue injury.  The local adaptation syndrome occurs SYMPATHETIC NERVOUS SYSTEM RESPONSE in small, topical injuries TO STRESS o Rapid and short-lived 3 o Causes stimulation of the adrenal-medullary response SYMPATHETIC-ADRENAL MEDULLARY IMMUNOLOGIC RESPONSE RESPONSE TO STRESS o Research findings show that the immune o Stimulated by SNS response system is connected to the neuroendocrine o Causes release of catecholamines from the and autonomic systems. adrenal medulla: o Lymphoid tissue  Epinephrine  richly supplied by autonomic nerves  Norepinephrine capable of releasing a number of different o The action of these hormones is similar to that neuropeptides that can have a direct effect of the sympathetic nervous system and has the on leukocyte regulation and the effect of sustaining and prolonging its actions. inflammatory response. o Resistance phase of GAS o Neuroendocrine hormones  released by the central nervous system HYPOTHALAMIC-PITUITARY RESPONSE and endocrine tissues can inhibit or o Longest-acting phase of the physiologic stimulate leukocyte function. response o The hypothalamus secretes Corticotropin- MALADAPTIVE RESPONSES TO STRESS Releasing Factor (CRF) or Corticotropin-  When responses to stress are ineffective Releasing Hormone (CRH), which stimulates  Chronic, recurrent responses or patterns of the anterior pituitary to produce ACTH. response over time that do not promote the o ACTH in turn stimulates the adrenal cortex to goals of adaptation. produce glucocorticoids, primarily cortisol. NURSING IMPLICATIONS FOR STRESS o Cortisol stimulates protein catabolism,  Major role: Early identification of both releasing amino acids; stimulates liver uptake physiologic and psychological stressors of amino acids and their conversion to glucose remains (gluconeogenesis); and inhibits glucose uptake  The nurse should be able to relate the (anti-insulin action) by many body cells but not presenting signs and symptoms of distress to those of the brain and heart. the physiology they represent and identify the o These cortisol-induced metabolic effects individual’s position on the continuum of provide the body with a ready source of energy function, from health and compensation to during a stressful situation. pathophysiology and disease.  The patient and the nurse would identify both individual and environmental stressors and discuss strategies to decrease the lifestyle stress, with the ultimate goal being to create a healthy lifestyle and prevent hypertension and its sequelae. 4 Lesson 2: Cellular Injury and Inflammatory increase in influence of a girl in puberty Process number of or of a pregnant new cells woman CONTROL OF THE STEADY STATE (increase in Regeneration of  Compensatory mechanisms- controlled by mitosis) liver cells ANS in response to stress New red blood cells in blood loss  Negative Feedback Mechanisms Dysplasia- Reproduction of Alterations in o Monitor the internal environment and change in the cells with epithelial cells of restore homeostasis when conditions appearance of resulting the skin or the shift out of the normal range cells after they alteration of cervix, producing (homeostasis). have been their size and irregular tissue o Work by sensing deviations from a subjected to shape changes that predetermined set point or range of chronic could be the adaptability and triggering a response irritation precursors of a aimed at offsetting the deviation. malignancy o Blood pressure, acid–base balance, Metaplasia- Stress applied Changes in blood glucose level, body temperature, transformation to highly epithelial cells and fluid and electrolyte balance of one adult specialized cell lining bronchi in cell type to response to  Positive Feedback Mechanisms another smoke irritation o Perpetuates the chain of events set in (reversible) (cells become motion by the original disturbance less specialized) instead of compensating for it. o As the system becomes more CELLULAR INJURY unbalanced, disorder and disintegration  Disorder in steady state regulation which occur. causes functional or structural damage o Blood clotting in humans (please see  Any stressor that alters the ability of the cell coagulation cascade) or system to maintain optimal balance of its adjustment processes will lead to injury.  Cellular responses to stress depend: o Host factors: type of cell and tissue involved o Factors pertaining to injuring agents: extent and type of injury (e.g. for infectious agents their pathogenicity or CELLULAR ADAPTATION TO STRESS virulence) Adaptation Stimulus Example  Four aspects of pathology to consider in Hypertrophy- Increased Leg muscles of cellular injury: increase in workload runner o Etiology: The cause cell Arm muscles in o Pathogenesis: Mechanisms of size leading to tennis player development increase in Cardiac muscle in o Morphological changes: Structural organ size person with alterations in cells and organs hypertension o Clinical significance: functional Atrophy- Decrease in: Secondary sex consequences of the morphological shrinkage in  Use organs in aging changes size of cell,  Blood person leading to supply Extremity  Causes of cell injury: decrease in  Nutrition immobilized in o Genetic organ size  Hormonal plaster cast stimulation  Innervation Hyperplasia- Hormonal Breast changes 5  o Acquired  It is a nonspecific response (not dependent on 1. Hypoxia a particular cause) that is meant to serve a  Inadequate cellular oxygenation protective function which interferes with the cell’s ability to transform energy  Causes:  A decrease in blood supply to an area (Ischemia)  A decrease in the oxygen- carrying capacity of the blood (decreased hemoglobin)  A ventilation/perfusion or respiratory problem that reduces the amount of oxygen available in the blood  A problem in the cell’s enzyme system that makes it unable to use the oxygen delivered to it 2. Nutritional Imbalance  A relative or absolute deficiency or excess of one or more essential nutrients.  Undernutrition: inadequate consumption of food or calories  Overnutrition: caloric excess 3. Physical agents  Temperature extremes, radiation, electrical shock, and mechanical trauma  The duration of exposure and the Chemical Mediators of Inflammation intensity of the stressor determine the severity of damage. Vasodilation Pain Prostaglandins E2, D2, F2, I2 PGE2, 4. Chemical agents Nitric Oxide Bradykinin  Poisons or heavy metals  Drugs and alcohol Increased Vascular Fever Permeability 5. Infectious agents Histamine, Serotonin IL-1, IL-6, TNF  Viruses, bacteria, rickettsiae, Bradykinin PGE2, mycoplasmas, fungi, protozoa, and C3a and C5a (through nematodes. liberating amines) Leukotrienes C4,D4.E4 6. Immune response PAF (AGEPC)  Hypoactive response: oxygen free radicals immunodeficiency  Hyperactive response: Chemotaxis Tissue Damage hypersensitivity and autoimmune C5a Neutrophil and responses Leukotriene B4 macrophage INFLAMMATION IL-8 lysosomal enzymes  Defensive reaction intended to neutralize, Bacterial products Oxygen derived free control, or eliminate the offending agent and to radicals prepare the site for repair. Nitric Oxide 6  o Labile cells  Multiply constantly to replace cells worn out by normal physiologic processes  Include epithelial cells of the skin and those lining the gastrointestinal tract o Permanent cells  Destruction to this type of cells cause permanent loss  Include neuron cell bodies o Stable cells  Have a latent ability to regenerate.  Under normal physiologic processes, they are not shed and do not need replacement, but if they are damaged or destroyed, they are able to regenerate.  Include functional cells of the kidney, liver, and pancreas.  Healing by replacement o Primary intention healing Types of Inflammation  The wound is clean and dry and the Inflammation Acute Chronic edges are approximated, as in a Causative Pathogens, Persistent acute surgical wound. agent injured tissues inflammation  Little scar formation occurs, and the due to non- wound is usually healed in a week. degradable pathogens, o Secondary intention healing persistent foreign  The wound or defect is larger and bodies, or gaping and has necrotic or dead autoimmune material. The wound fills from the reactions bottom upward with granulation tissue. Major cells Neutrophils, Mononuclear cells  The process of repair takes longer and involved mononuclear (monocytes, results in more scar formation, with loss Cells macrophages, of specialized function. (monocytes, lymphocytes, macrophages) plasma cells), NURSING IMPLICATIONS fibroblasts  Assessment considerations Primary Vasoactive IFN-y and other o Are the heart rate, respiratory rate, and mediators amines, cytokines, temperature normal? eicosanoids growth factors, o What emotional distress may be reactive oxygen contributing to the patient’s health species, hydrolytic problems? enzymes o Are there other indicators of steady-state Onset Immediate Delayed deviation? Duration Few days Up to many months o What is the person’s blood pressure, or year height, and weight? Outcomes Resolution, tissue destruction, o Are there any problems in movement or abscess fibrosis sensation? formation, o Does the person demonstrate any chronic problems with affect, behavior, speech, inflammation cognitive ability, orientation, or memory? o Are there obvious impairments, lesions, or CELLULAR HEALING deformities?  Healing by regeneration- depend on cell type 7 Lesson 3: Pain and Pain Management  Unlike acute pain, it serves no purpose and may become the patient’s primary problem  Cancer-related pain  Pain associated with cancer may be acute or chronic  It is the second most common fear of PAIN cancer patients  An unpleasant sensory and emotional  May be: experience associated with actual or  Directly associated with the potential tissue damage (Merskey & cancer eg, bony infiltration with Bogduk, 1994). tumor cells or nerve compression  It is the most common reason for seeking (most common), health care.  A result of cancer treatment eg,  “Whatever the person says it is, existing surgery or radiation, whenever the experiencing person says it  Or not associated with the cancer does” McCaffery & Pasero, 1999 eg, trauma  Pain is a protective mechanism or a warning to prevent further injury 2. According to location  Pain specified according to the site or location of pain eg cardiac pain, pelvic pain etc.  This is helpful in communicating and treating pain TYPES OF PAIN 3. According to etiology 1. According to duration  Pain specified according to the cause eg  Acute pain  Recent onset burn pain  This is also helpful in communicating and  Lasting seconds to 6 months (however, the expected time of treating pain healing should be considered such 4. According to cause that if pain occurs beyond the  Nociceptive pain expected healing time, then it will  Pain arising from tissue damage considered and treated as chronic  May be acute or chronic pain)  Commonly associated with a specific  Neuropathic pain injury  Pain arising from damage of the  Indicates that damage or injury has occurred nerves that relay pain to the brain  Mostly chronic  Usually decreases along with healing if no lasting damage has occurred  Others  Pain arising from neurological  Chronic (Non-malignant) pain dysfunction not damage eg fibromyalgia  Is constant or intermittent pain that persists beyond the expected healing time  Can seldom be attributed to a specific cause or injury. EFFECTS OF PAIN  May have a poorly defined onset  Effects of acute pain  Is often difficult to treat because the o Can affect the pulmonary, cause or origin may be unclear. cardiovascular, gastrointestinal,  pain may be defined as pain that lasts endocrine, and immune systems. The for 6 months or longer stress response 8  o Causes stress (“neuroendocrine o Algogenic substances response to stress”) and therefore  Pain-causing substances triggers the physiologic effects of stress  Substances that affect the sensitivity o The widespread endocrine, immunologic, of nociceptors are released into the and inflammatory changes that occur extracellular tissue as a result of with stress can have significant negative tissue damage. effects. This is particularly harmful in patients compromised by age, illness, or Substance Source Effect injury. Bradykinin Macrophages Activates o May also interfere with some physiologic and plasma nociceptors functions eg pain in the chest may kininogen interfere with ventilation or pain in the lower extremities may hinder ambulation. Serotonin Platelets Activates nociceptors  Effects of chronic pain o Suppression of the immune function Histamine Platelets and Produces associated with chronic pain may mast cells vasodilation, promote tumor growth. edema and o Chronic pain often results in depression pruritus and disability. Potentiates the PATHOPHYSIOLOGY OF PAIN response of  Nociceptors (pain receptors) nociceptors to o Free nerve endings or receptors that are bradykinin preferentially sensitive to a noxious Prostaglandin Tissue injury Sensitize (painful) stimulus. and nociceptors o Noxious stimulus may be mechanical, cyclooxygenas thermal, or chemical in nature e pathway o Found in skin, skeletal muscle, fascia, Leukotriene Tissue injury Sensitize tendon and cornea and nociceptors o Some nociceptors respond to only one lipooxygenase type of stimulus (unimodal) others are pathway sensitive to all types (polymodal) Excess H* Tissue injury Increases pain o Receptors transfer noxious stimuli into ions and ischemia and hyperalgesia action potential associated with inflammation  Nociception Cytokines Macrophages Excite and o Transmission of pain (e.g., sensitize o Increased by algogenic substances interleukins nociceptors o Pain impulses travel and tissue  First order neuron in the dorsal root necrosis ganglion entering the SC into dorsal factor) horn Adenosine Tissue injury Pain and  Second order neuron found in Rexed hyperalgesia laminae (Laminae II found in Substansia gelatinosa of SC which Neurotransmi Antidromic Substance P decussates anteriorly and ascends to tters (e.g., release by activates the ventral posterolateral (VPL) glutamate peripheral macrophages and nucleus of thalamus via spinothalamic and nerve terminals Mast cells tract substance P) following tissue  Third order neurons found in the VPL injury Glutamate nucleus of thalamus which terminates activates in ipsilateral post-central gyrus nociceptors (somatosensory cortex) Nerve growth Macrophages Stimulates mast factor cells to release 9  histamine and dorsal horn, the dorsal column fibers, serotonin and the central transmission cells  The noxious impulses are influenced Induces heat by a “gating mechanism.” hyperalgesia  Stimulation of large fibers “closes” the gate thus inhibiting pain transmission Sensitizes  Stimulation of small fibers “opens’ the nociceptors gate allowing nociception  Nerve fibers that transmit pain o A delta fibers  Smaller and myelinated  Transmits rapid, fast pain FACTORS AFFECTING PAIN RESPONSE  Past experience o C fibers o The way a person responds to pain is a  Larger and unmyelinated result of many separate painful events  Transmits “second pain” during a lifetime  Dull, aching and burning quality o People who have experienced pain may experience more fear and anxiety  Endorphins and enkephalins towards it. o Chemicals that reduce or inhibit the o This may be determined by the transmission or perception of pain characteristics of previous pain o Morphine-like substances that produce experienced and the promptness and analgesia adequacy of pain relief done.  Descending control system  Anxiety and depression o A system of fibers that originate in the o Research has demonstrated no lower and midportion of the brain consistent relationship between anxiety (specifically the periaqueductal gray and pain matter) and terminate on the inhibitory interneuronal fibers in the dorsal horn of  Culture the spinal cord. o Beliefs about pain and how to respond to o It prevents continuous transmission of it differ from one culture to the next. stimuli as painful, partly through the o Culture determines what responses to action of the endorphins. pain are acceptable or unacceptable. o As nociception occurs, the descending o Cultural factors must be taken into control system is activated to inhibit pain. account to effectively manage pain o Inhibitory interneuronal fibers  Age  The interconnections between the o The way an older person responds to descending neuronal system and the pain may differ from the way a younger ascending sensory tract person responds.  Contains enkephalins o Because elderly people have a slower  Activated by activity of non-nociceptor metabolism and a greater ratio of body peripheral fibers (fibers that normally fat to muscle mass than younger people, do not transmit painful or noxious small doses of analgesic agents may be stimuli) sufficient to relieve pain, and these doses may be effective longer (Buffum & o Gate Control Theory (Melzack and Wall, Buffum, 2000). Elderly 1965)  Stimulation of the skin evokes nervous  Gender impulses that are then transmitted by three systems located in the spinal  Placebo effect cord: substantia gelatinosa in the o Occurs when a person responds to the medication or other treatment because of 10  an expectation that the treatment will  NURSES’ ROLE IN PAIN MANAGEMENT work rather than because it actually does o Identifying goals for pain management so.  Goals depend on the characteristics of o Results from the natural (endogenous) the patient’s pain. production of endorphins in the descending control system. o Establishing nurse-patient relationship and teaching  Key to managing analgesia in the patient with pain, because open communication and patient  Characteristics of pain cooperation are essential to success. o Intensity  Include family in teaching.  Ranges from none to mild discomfort to excruciating o Providing physical care  Is influenced by the person’s pain  Pain may hinder ADLs or self-care threshold and pain tolerance activities  Assessed using pain scales  Depends on self-care deficit experienced by client o Timing  Helps provide comfort  Information about the onset (sudden  Gives the nurse an opportunity to or gradual), duration, relationship perform a complete assessment and between time and intensity, and to identify problems that may whether there are changes in rhythmic contribute to the patient’s discomfort patterns. and pain o Location o Managing anxiety related to pain  Best determined by having the patient  Anxiety may affect a patient’s point to the area of the body involved response to pain  Radiating vs referred pain  Teach the patient about the nature of the impending painful experience and o Quality the ways to reduce pain to help  Patient’s description of the pain using manage anxiety his/her own words  Patient education is key. o Personal meaning  Patients experience pain differently, and the pain experience can mean many different things.  It is important to ask how the pain has affected the person’s daily life. PAIN MANAGEMENT  Pain Management Strategies o Aggravating and alleviating factors o Goal: Pain relief  Anything makes the pain worse and  Requires close collaboration and what makes it better and asks communication with physician or specifically about the relationship primary care provider between activity and pain. o Pharmacologic Interventions o Pain behaviors  Nurse’s role: maintain analgesia,  Non-verbal and behavioural assess effectiveness, report when expressions of pain intervention is ineffective or if it  Not consistent or reliable indicator of produces side effects pain intensity and quality  Routes: oral, rectal, transdermal, transmucosal, intraspinal and epidural 11   Premedication assessment  Can be used for both oral  Ask about allergies and nature of analgesics and continuous previous allergic response infusions of opioids (IV, Subq and (opiates) epidural routes)  Obtain health history including medication history o Local anesthetic agents  Assess pain status before  Work by blocking nerve conduction administration of analgesics when applied directly to the nerve fibers o Approaches for analgesic use  Topical application  Balanced anesthesia  Applied directly to the site of injury  Refers to more than one form of  Rapidly absorbed in the analgesia concurrently to obtain more bloodstream (increased risk for pain relief with fewer side effects toxicity); accompanied by a  Use lower dose of analgesics vasoconstrictive agent to  Categories of analgesics: decrease systemic absorption and  NSAIDs maintain concentration at injury  Opioids site  Local anesthesia  Intraspinal administration  Pro re nata (PRN)  Local anesthetic administered via  “as needed” epidural catheter  This approach leaves the patient  Applied directly on the nerve roots sedated or in severe pain  For acute pain but also used for  For opioid analgesics, serum pain management levels must be maintained  Can be continuous in low doses,  Give large doses to ensure intermittently on schedule or PRN enough periods of sedation o Opioid analgesic agents  Preventive approach  Can be administered in various routes  Currently considered the most  Goal: relieve pain and improve quality effective strategy of life  Therapeutic serum levels is  Factors in determining route, dose maintained and frequency:  Analgesics are administered at a  Characteristics of pain set time interval  Overall status of patient  Requires smaller dosage because  Patient’s response to analgesic pain does not escalate to highest  Patient’s report of pain intensity  Anticipate and consider side effects  Individualized dosage  Respiratory depression and  Dosage and interval of dosage is sedation based on patient’s requirements  Most serious side effect of IV  Requires close monitoring of opioids patient especially after the first  Relatively rare due to dose is administered to assess administration of small doses patient’s response.  Risk factors:  Age  Patient-Controlled Analgesia  Concomitant use of other  Used for post-operative pain and opioids and other CNS drugs chronic pain  Central catheter  Allows patients to control the  Increased intraabdominal and administration of their medication intrathoracic pressure with predetermined safety limits 12   Nursing responsibilities  COX is a rate limiting enzyme involved  Frequent assessment of in mediating prostaglandin formation patient receiving IV opioids in injured cells (decrease in RR, shallow respiration) o Tricyclic antidepressants (TCAs) and  Monitor for tolerance (no Anticonvulsants sedation)  For pain of neurologic origin  Assess for complications of (neuralgias and neuropathic pain) sedation and immobility  Pain with dysesthesia (burning or cutting pain)  Nausea and vomiting  Usually occurs after initial dose  May be triggered by position changes  Adequate hydration and anti- emetics may decrease incidence  Constipation  Common side effect  High fluid and fiber diet, mild laxatives  Inadequate pain relief  Commonly associated with inadequate dose due to underestimation of pain or changing route of administration  Other side effects  Impaired metabolism and excretion in patients with liver and kidney disease.  Patients with hypothyroidism  Dehydrated patients are at higher risk of hypotensive effects of opioids  Patients receiving other CNS drugs may have experience o Non-pharmacologic interventions exaggerated depressant effects  Cutaneous stimulation and massage  Ice and heat therapies o Tolerance and addiction  Transcutaneous Electrical Nerve  Tolerance- the need for increasing Stimulation (TENS) doses to achieve the same therapeutic  Distraction effects  Relaxation techniques  Seen in patients taking opioids for  Guided imagery a long period of time  Hypnosis  Addiction is a behavioral pattern of substance use characterized by a NONPHARMACOLOGIC INTERVENTIONS compulsion to take the drug primarily (PEDIATRIC AND ADULT)* to experience a psychic effect. Physical (Sensory) Cognitive-Behavioral Interventions Interventions o Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Comfort positioning Psychological preparation,  Decreases pain by inhibiting cyclo- education, or coaching oxygenase (COX) Cutaneous Distraction tools: movies, 13 stimulation games, videos, apps, toys with light/sound, bubbles Nonnutritive sucking Relaxation techniques (breathing, meditation, etc.) Pacifier +/- sucrose Music and singing solution Pressure, massage Guided imagery Hot or Cold Conversation and treatments therapeutic language o Neurologic and neurosurgical approaches  Indicated for chronic pain  Cordotomy  Division of nerve tracts of the spinal cord  Performed to interrupt pain transmission  Rhizotomy  Sensory nerve roots are destroyed where they enter the spinal cord 14 Lesson 4 PART 1: Preoperative Nursing Care o Informed consent is confirmed, o Intravenous infusion is started o Preoperative medicines are administered as ordered 2. INTRAOPERATIVE PHASE  Begins when the patient is transferred onto the operating room table and ends when he or she is admitted to the postanesthesia care unit (PACU). PERIOPERATIVE NURSING MANAGEMENT  Scope of nursing role To help us without discussion, let us visit the case o Providing for the patient’s safety; of Nina. o Maintaining an aseptic environment o Ensuring proper function of equipment; o Providing the surgeon with specific instruments and supplies for the surgical field; and o Completing appropriate documentation.  Other roles: o Providing emotional support to the patient o Assisting in proper positioning of the patient Perioperative and Perianesthesia Nursing  Includes a wide variety of nursing functions 3. POSTOPERATIVE PHASE associated with the patient’s surgical  Begins with the admission of the patient to experience during the perioperative period the PACU and ends with a follow-up  Addresses the nursing roles in each phase evaluation in the clinical setting or at home. of the surgical experience.  Scope of nursing role o Immediate postoperative phase Phases of the Surgical Experience  Maintaining the patient’s airway, 1. PREOPERATIVE PHASE  Monitoring vital signs,  Begins when the decision to proceed with  Assessing the effects of the surgical intervention is made and ends with anesthetic agents, the transfer of the patient onto the operating  Assessing the patient for room table complications, and  Scope of nursing role  Providing comfort and pain o Establishing a baseline evaluation of relief. the patient before the day of surgery o Promoting the patient’s recovery by carrying out a preoperative o Initiating the teaching, follow-up care interview and referrals essential for recovery o Ensuring that necessary tests have and rehabilitation after discharge. been or will be performed (preadmission testing) o Arranging appropriate consultative services o Providing preparatory education about recovery from anesthesia and postoperative care  Nursing roles on the day of surgery o Patient teaching is reviewed o Patient’s identity and the surgical site are verified 15  3. BASED ON DEGREE OF INVASIVENESS  Minimally invasive surgery o Does not require a large incision o Allows the patient to recuperate faster with less pain. o Example: Laparoscopy, Endoscopy, Categories of Surgery Based on Urgency Arthroscopy  Open surgery Classification Indications Examples o Cutting of skin and tissues so that for Surgery the surgeon has a full view of the I. Emergent- Without Severe bleeding structures or organs involved Patient requires delay Bladder or immediate at- intestinal 4. BASED ON PURPOSE tention; disorder obstruction  Diagnostic surgery may be life- Fractured skull o Exploratory surgery threatening Gunshot or stab  Diagnostic method used by wounds doctors when trying to find a Extensive burns diagnosis for an ailment. II. Urgent-Patient Within 24- Acute  Is used most commonly to requires prompt 30 h gallbladder diagnose or locate cancer. attention infection Kidney or o Biopsy ureteral stones  Done to remove a portion or III. Required- Plan within Prostatic sample of tissue for histo- Patient needs to a few hyperplasia pathological analysis have surgery weeks or without bladder months obstruction o Therapeutic surgery Thyroid  Treats a previously diagnosed disorders condition Cataracts IV. Elective- Failure to Repair of scars o Reparative surgery Patient should have Simple hernia  Done to repair the body due to have surgery surgery not Vaginal repair damage done by disease or catastrophic other causes V. Optional- Personal Cosmetic Decision rests preference surgery o Reconstructive or Cosmetic with patient surgery  A person chooses to have an Surgical Classifications operation, or invasive medical 1. BASED ON BODY PART procedure, to change their  Orthopedic surgery, neurosurgery, etc. physical appearance for cosmetic rather than medical 2. BASED ON EQUIPMENT USED reasons  Robotic surgery o Use of a surgical robot o Palliative surgery  Done to relieve pain or to correct  Microsurgery surgery an problem o Involves the use of an operating microscope for the surgeon to see small structures  Laser surgery o Use of a laser for cutting tissue instead of a scalpel or similar surgical instruments 16  c. Informed Subject  Informed consent should be in writing. It should contain the following:  Explanation of procedure and its risks  Description of benefits and alternatives  An offer to answer THE PREOPERATIVE PHASE questions about procedure  Instructions that the patient may withdraw consent  A statement informing the patient if the protocol differs Preparing the Client for Surgery from customary procedure  Informed Consent o Voluntary and written d. Patient Able to Comprehend o Necessary before non-emergent  Information must be written and surgery can be performed delivered in language o Purpose understandable to the patient.  Protects the patient from  Questions must be answered to unsanctioned surgery facilitate comprehension if  Protects the surgeon from material is confusing claims of an unauthorized operation o Informed consent is necessary in the following:  Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis  Procedures requiring sedation and/or anesthesia  A nonsurgical procedure, such  Assessment of the Health Factors that as an arteriography, that carries Affect Patient Preoperatively more than slight risk to the o Ensure that the patient to has as patient many positive health factors as  Procedures involving radiation possible o Criteria for a valid informed o Every attempt is made to stabilize consent those conditions that otherwise a. Voluntary Consent hinder a smooth recovery  Valid consent must be freely o Activities: given, without coercion.  Obtain a comprehensive health b. Incompetent Patient history  Legal definition: individual who  Perform physical examination is not autonomous and cannot noting the vital signs are noted give or withhold consent (eg,  Establish a database future individuals who are mentally comparisons retarded, mentally ill, or comatose) 17 Areas of assessment: 4. Hepatic and renal function 1. Nutritional and fluid status  Goal is optimal function of the liver and  Essential factor in promoting healing and urinary systems so that medications, resisting infection and other surgical aesthetic agents, body wastes, and toxins complications are adequately processed and removed  Provides information on obesity, from the body undernutrition, weight loss, malnutrition,  Poor function of these organs may imply deficiencies in specific nutrients, metabolic longer anaesthesia recovery time abnormalities, the effects of medications  Blood tests may be done to assess renal on nutrition, and special problems of the and hepatic function as indicated by hospitalized patient physician  Any nutritional deficiency should be corrected before surgery so that enough 5. Endocrine function protein is available for tissue repair  Assess for presence of Diabetes  Drug and alcohol use Mellitus o Alcohol and drug use may interact with o Patients with DM have higher risk of the effects of anaesthesia predisposing developing complications post-surgery the patient to complications due to possible poor kidney function, o Acute intoxication may increase risk of poor wound healing and hypertension injury  Assess corticosteroid use o Patients with chronic alcohol use often o Patients are at risk for adrenal suffer from malnutrition and other insufficiency problems which may increase risk of o Note the function of the adrenal complications; they may also response in physiologic adaptation to experience withdrawal symptoms stress. Patients with adrenal o The nurse must ask directly about insufficiency may be at higher risk information on drug and alcohol use as coping poorly to physical stress patients usually deny this.  Assess thyroid function o Thyroid function determines the body’ 2. Respiratory status metabolism  Goal is optimal respiratory function  Poor respiratory function may cause 6. Immune function potential complications because adequate  Determine the existence of allergies, ventilation is potentially compromised including the nature of previous allergic during all phases of surgery reactions.  Assess for infection and adequate  Identify and document any sensitivity to ventilation medications (or anaesthetic agents) and  Encourage and instruct to do breathing past adverse reactions to these agents. exercise to enhance lung capacity  Assess for latex allergy  Instruct clients who smoke to quit for at  Assess for presence of least 2 months before surgery immunosuppression  Assess for signs of infection like fever. 3. Cardiovascular status  Goal in preparing any patient for surgery is 7. Previous medication use to ensure a well-functioning cardiovascular  Medication history is obtained from each system to meet the oxygen, fluid, and patient because of the possible effects of nutritional needs of the perioperative medications on the patient’s perioperative period. and perianesthesia course and the  Assess cardiovascular function using possibility of drug interactions diagnostic procedures like ECG,  Because of possible adverse interactions, echocardiography as indicated by the the nurse must assess and document the physician. patient’s use of prescription medications,  Blood pressure and heart rate should be OTC medications (especially aspirin), and maintained at the normal level. herbal medications. The nurse must clearly 18  communicate this information to the  Cardiovascular, endocrine, hepatic, anesthesiologist or anesthetist. and biliary diseases 8. Psychosocial factors  Patients with Mental or Physical  Assess the patient’s emotional reaction to Disability the surgery he/she is about to undergo o Need for assistive devices  Assess the patient’s concerns, fears or o Modifications in preoperative teaching anxiety about the surgery. o Additional assistance with and attention  Counselling and proper education is to positioning or transferring needed. o Effects of the disability on surgery and  Ensure that the patient has psychosocial anaesthesia support system.  Patients undergoing Emergency 9. Spiritual and cultural beliefs Surgery  These play an important role on how o The special concern for emergency people cope with fear and anxiety. surgery is that there is LIMITED TIME  The beliefs of each patient should be to prepare the patient such that all respected and supported. activities done in the pre-operative  Respecting beliefs also facilitates rapport period must be performed in a and trust condensed or shorter amount of time 10. Special Considerations Preoperative Nursing Care  Obese Patients  Nursing Diagnoses: o Obesity increases the risk and severity o Anxiety related to the surgical of complications associated with experience (anesthesia, pain) and the surgery outcome of surgery o It also increases technical and o Fear related to perceived threat of the mechanical problems related to surgery surgical procedure and separation from o Patient may need assistance post- support system surgery due to difficulty on self-care o Knowledge deficit of preoperative o Obese patients are more susceptible to procedures and protocols and complications: postoperative expectations  Abdominal distention  Phlebitis Preoperative Teachings Intervention Rationale WHEN AND WHAT TO TEACH To allow the patient to assimilate information and Space instructions over a period of time ask questions as they arise. Combine teaching sessions with various preparation procedures To allow for an easy and timely flow of information. Guide the patient through the experience and allow ample time for questions. Some patients may feel too many descriptive Respect the patient’s wish for less detail. details will increase their anxiety level Go beyond descriptions of the procedure and should include explanations of the sensations the patient will To relieve patient’s anxiety experience. Perform teaching when client comes for pre-admission This is the ideal time for teaching visit or when preparation procedures are being done DEEP BREATHING, COUGHING AND INCENTIVE SPIROMETER GOAL: (Deep breathing and incentive spirometer) to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. 19 GOAL: (Coughing) to mobilize secretions so they can be removed. Deep breathing before coughing stimulates the cough reflex MOBILITY AND ACTIVE BODY MOVEMENT To improve circulation, prevent venous stasis, and promote optimal respiratory function. To facilitate cooperation especially during the post-op Explain the rationale for the exercises period Demonstrate the different exercises To ensure client safety when performing them PAIN MANAGEMENT So that the patient may differentiate postoperative pain Assess client’s awareness of acute and chronic pain from a chronic condition Introduce and explain the use of the pain scale For better post-operative pain assessment Instruct patient about post-operative medications for For adequate pain relief and better compliance pain COGNITIVE COPING STRATEGIES May be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation Preoperative Psychosocial Interventions 1. Reducing anxiety 2. Decreasing fear  Adequate and appropriate pre-operative  Assist the patient to identify coping teaching is helpful to decrease anxiety strategies previously used  Other measures:  Encourage family or social support groups o Distraction o Imagery 3. Respecting cultural, spiritual and o Optimistic self-recitation (e.g. “All is religious beliefs well”) o Use of music 20 General Preoperative Nursing Interventions Intervention Rationale MANAGING NUTRITION AND FLUIDS Withhold food and fluids as recommended To prevent aspiration To ensure adequate fluid status during the Maintain a IVF and patent IV line procedure PREPARING THE BOWEL To allow good visualization of the surgical site and to prevent trauma to the intestine or contamination of Administer cleansing enema as ordered the night the peritoneum by feces before the procedure Cleansing enemas are commonly prescribed for patients undergoing abdominal or pelvic surgeries Administer antibiotics as prescribed To reduce intestinal flora PREPARING THE SKIN Provide appropriate skin care To decrease bacteria without injuring the skin Immediate Preoperative Nursing Interventions o Note any unusual or last-minute findings  Physically preparing the client for the that may affect anesthesia or the surgery surgery o Transporting the patient o the pre- o Assist client to change into surgical gown surgical area and cap o Transport client to OR holding area 30-60 o Remove dentures and jewelry minutes before the surgery o Let the client void o Ensure the patient is comfortable and warm  Administering preanesthetic medications o Administer as prescribed  Attending to the family needs o Ensure patient safety after administration o Inform the family of the possible condition by keeping side rails raised of the patient after surgery (i.e. he may have tubes in place or may be  Maintaining preoperative record unconscious, etc.) o Ensure completion of the pre-operative checklist 21 Lesson 4 PART 2: Intraoperative Nursing Care operation to ensure the patient’s safety and well-being. INTRAOPERATIVE PHASE  After the surgery: The Surgical Team o Counts all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient (together with scrub nurse). o Sends specimen obtained during surgery to the laboratory 3. The scrub nurse  Performing a surgical hand scrub  Setting up the sterile tables  Preparing sutures, ligatures, and special equipment (such as a laparoscope)  Assisting the surgeon and the surgical assistants during the procedure by  anticipating the instruments that will be required, such as sponges, drains, and other equipment  After the surgery: o Counts all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient. o Labels tissue specimens obtained 1. The patient during surgery 2. The circulating nurse 4. The surgeon  Manages the operating room  Performs the surgical procedure  Protects the patient’s safety and health by  Heads the surgical team monitoring the activities  Of the surgical team 5. The anesthesiologist/ anesthetist  Checking the operating room conditions  Anesthesiologist- is a physician specifically  Continually assessing the patient for signs trained in the art and science of of injury and implementing appropriate anesthesiology. interventions.  Anesthetist- is a qualified health care  Main responsibilities professional who administers anesthetics o Verifying consent  Roles: o Coordinating the team o Interviews and assesses the patient o Ensuring cleanliness, proper prior to surgery temperature, humidity, and lighting o Selects the anesthesia o Ensures the safe functioning of o Administers the anesthesia equipment o Intubates the patient if necessary to o Ensures availability of supplies and maintain the client’s airway materials o Manages any technical problems o Monitors aseptic practices to avoid related to the administration of the breaks in technique while coordinating anesthetic agent the movement of related personnel o Supervises the patient’s condition (medical, radiography, and laboratory) throughout the surgical procedure o Implements fire safety precautions through monitoring of the patient’s o Monitors the patient and documents status specific activities throughout the 22  The Surgical Environment Three zones of surgical area  UNRESTRICTED ZONE (INTERCHANGE) o Where street clothes are allowed  SEMIRESTRICTED ZONE o Where attire consists of scrub clothes and caps  RESTRICTED ZONE o Where scrub clothes, shoe covers, caps, and masks are worn o Masks are worn at all times Principles of Surgical Asepsis o The surgeons and other surgical team  Use only sterile items within a sterile field; members wear additional sterile  Sterile (scrubbed) personnel are gowned clothing and protective devices during and gloved; the operation.  Sterile personnel operate within a sterile field (sterile personnel touch only sterile Interchange Semi- Restricted Dirty items or areas, unsterile personnel touch Restricted only unsterile items or areas); Patient Induction Operating Disposal  Sterile drapes are used to create a sterile Reception rooms rooms Area field;  All items used in a sterile field must be Locker rooms Clean Sterile sterile; storage supply  All items introduced onto a sterile field rooms storage should be opened, dispensed, and areas transferred by methods that maintain Lounges Scrub areas sterility and integrity; Offices Recovery  A sterile field should be maintained and rooms monitored constantly; and  Surgical staff should be trained to recognize when they have broken technique and should know how to remedy the situation. General Rules of Aseptic Technique RULE RATIONALE Movement out of the Surgical team members sterile area may remain within the sterile encourage cross- area. contamination. Talking releases Talking is kept to a moisture droplets laden minimum. with bacteria. Movement in the Movement in the OR may operating room (OR) by encourage turbulent all personnel is kept to a airflow, resulting in cross- minimum; only necessary contamination. 23 personnel should enter o Patients under general anesthesia are the operating room. not arousable, even to painful stimuli. Dust, lint, or other o They lose the ability to maintain Non-scrubbed personnel ventilatory function and require vehicles of bacterial do not reach over sterile assistance in maintaining a patent contamination may fall on fields. airway. the sterile field. A team member’s back is o Cardiovascular function may be Scrubbed team members impaired as well not considered sterile face each other and the even if wearing a sterile field at all times. wraparound gown. Equipment used during Unsterile instruments surgery must be may be a source of sterilized. cross-contamination. Scrubbed personnel 1. STAGE 1: BEGINNING ANESTHESIA Non-scrubbed personnel  Warmth, dizziness, and a feeling of handle only sterile items; and non-sterile items detachment may be experienced. non-scrubbed personnel may be sources of cross-  May have a ringing, roaring, or buzzing in handle only non-sterile contamination. the ears and, though still conscious, may items. If the sterility of an item is Non-sterile, sense an inability to move the extremities questioned, it is contaminated equipment easily. considered may be a sourc