Chamberlain College of Nursing :NR 226 Final Exam Study Outline 1 Latest,100% CORRECT

Chamberlain College of Nursing :NR 226 Final Exam Study Outline 1 Latest *****ADPIE for ALL!!**** The Nursing Process o The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge) to actual or potential health problems. Use of the process allows nurses to help patients meet agreed-on outcomes for better health. o The nursing process requires a nurse to use the general and specific critical thinking competencies described earlier to focus on a particular patient's unique needs. The format for the nursing process is unique to the discipline of nursing and provides a common language and process for nurses to “think through” patients' clinical problems • 5 Steps of the Nursing Process (ADPIE) o Assessment ▪ Phases of interview/assessment • An interview is an approach for gathering subjective and objective data from a patient through an organized conversation. An initial interview involves collecting a nursing health history and gathering information about a patient's condition • 1. Orientation and Setting an Agenda o Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Explain why you are collecting data and assure patients that all of the information will be confidential. o Your aim is to set an agenda for how you will gather information about a patient's current chief concerns or problems. Remember, the best clinical interview focuses on a patient's goals, preferences, and concerns and not on your agenda. • 2. Working Phase-Collecting Assessment or Nursing Health History o Start an assessment or a nursing health history with open- ended questions that allow patients to describe more clearly their concerns and problems. For example, begin by having a patient explain symptoms or physical concerns and describe what he or she knows about the health problem or ask him or her to describe health care expectations. o Use attentive listening and other therapeutic communication techniques that encourage a patient to tell his or her story. • 3. Terminating an Interview o Termination of an interview requires skill. You summarize your discussion with a patient and check for accuracy of the information collected. Give your patient a clue that the interview is coming to an end. For example, say, “I have just two more questions. We'll be finished in a few more minutes.” o This helps a patient maintain direct attention without being distracted by wondering when the interview will end. ▪ Methods of obtaining data • An assessment is necessary for you to gather information to make accurate judgments about a patient's current condition. Your information comes from: • The patient through interview, observations, and physical examination. • Family members or significant others' reports and response to interviews. • Other members of the health care team. • Medical record information (e.g., patient history, laboratory work, x-ray film results, multidisciplinary consultations). • Scientific and medical literature (evidence about disease conditions, assessment techniques, and standards). ▪ Subjective Data • Subjective data are your patients' verbal descriptions of their health problems. For example, Mr. Lawson's self-report of pain at the area where his incision slightly separated is an example of subjective data. Subjective data include patients' feelings, perceptions, and self-report of symptoms. • Only patients provide subjective data relevant to their health condition. The data often reflect physiological changes, which you further explore through objective review of body systems. ▪ Objective Data • Objective data are observations or measurements of a patient's health status. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. o Diagnosis • Objective data is measured on the basis of an accepted standard such as the Fahrenheit or Celsius measure on a thermometer, inches or centimeters on a measuring tape, or a rating scale (e.g., pain). • When you collect objective data, apply critical thinking intellectual standards (e.g., clear, precise, and consistent) so you can correctly interpret your findings. ▪ Identify components of the nursing diagnostic statement • The diagnostic reasoning process involves using the assessment data you gather about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. • The diagnostic process flows from the assessment process and includes decision-making steps. These steps include data clustering, identifying patient health problems, and formulating the diagnosis. ▪ Identify assessment findings, goals, interventions, evaluations appropriate to a specific nursing diagnosis. • Be able to recognize the difference between each category. Context clues like “The Patient will…” means it is a goal. o Planning ▪ Components of goal/outcome statement • A patient-centered goal reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs, abilities, and resources. A patient-centered goal or outcome reflects a patient's specific behavior, not your own goals or interventions. • Goals and expected outcomes direct your nursing care. Once you set a patient-centered goal for a nursing diagnosis, the expected outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of the patient's health problems. • Usually you develop several expected outcomes for each nursing diagnosis and goal. For a patient to resolve a goal, several measurable outcomes are needed to ensure that the goal is met. In the case of Mr. Lawson's diagnosis of Risk for Infection, Tonya knows that more than one outcome is needed to ensure that the patient is infection free. • The SMART acronym (Specific, Measurable, Attainable, and Realistic, Timely) is a useful approach for writing goals and outcome statements more effectively. o Implementation ▪ Independent nursing interventions • Nurse-initiated interventions are the independent nursing interventions or actions that a nurse initiates without supervision or direction from others. • Examples include positioning patients to prevent pressure ulcer formation, instructing patients in side effects of medications, or providing skin care to an ostomy site. Independent nursing interventions do not require an order from another health care provider. ▪ Dependent nursing interventions • Health care provider–initiated interventions are dependent nursing interventions, or actions that require an order from a health care provider. The interventions are based on the health care provider's response to treating or managing a medical diagnosis. • Advanced practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are also able to write dependent interventions. • As a nurse you intervene by carrying out the health care provider's written and/or verbal orders. Administering a medication, implementing an invasive procedure (e.g., inserting a Foley catheter, starting an intravenous [IV] infusion) and preparing a patient for diagnostic tests are examples of health care provider- initiated interventions. ▪ Direct care activities • Direct care interventions are treatments performed through interactions with patients. For example, a patient receives direct intervention in the form of medication administration, insertion of a urinary catheter, discharge instruction, or counseling during a time of grief. ▪ Indirect care activities • Indirect care interventions are treatments performed away from a patient but on behalf of the patient or group of patients (e.g., managing a patient's environment [e.g., safety and infection control]), documentation, and interdisciplinary collaboration. o Evaluation ▪ Elements of the evaluation process • Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves. • You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful. • You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, patient interview). • In fact, evaluative measures are the same as assessment measures, but you perform them at the point of care when you make decisions about a patient's status and progress. The intent of assessment is to identify which, if any, problems exist. The intent of evaluation is to determine if the known problems have remained the same, improved, worsened, or otherwise changed. • Professional Practice o Delegation ▪ 5 rights 1. Right task – ones that are repetitive and require little supervision, relatively noninvasive, results that are predictable, minimal risk (ex: specimen collection, ambulating stable pts, prepping room for pt. admit) 2. Right Circumstances – patient setting, available resources 3. Right person – make sure that the tasks match the person’s level of expertise 4. Right Direction / Communication – give clear, concise descriptions of the task including its objective, limits, and expectations 5. Right Supervision/ Evaluation – provide appropriate monitoring, evaluation, intervention when needed, and feedback ▪ supervision o Prioritization of care – organization of vison of desired outcomes for a patient ▪ High Priority – immediate threat to patient’s survival or safety (ex: obstructed airway, loss of consciousness, psychological episode of anxiety attack, ABC’s) ▪ Intermediate Priority – non-emergency, nonlife threatening actual or potential needs that a pt. and family members are experiencing (ex: teaching needs of pt. related to a new drug, taking measures to decrease post-operative complications) ▪ Low Priority – actual or potential problems that are not directly related to a patient’s illness or disease. (ex: developmental needs or long-term health care needs such as self-care at home) o Nursing care delivery model 1. Traditional Models ▪ Team nursing – developed in response to severe nursing shortage ▪ Primary nursing – developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members ▪ Patient and family centered – mutual partnerships among the patient, family, and health care team are formed to plan, implement and evaluate the nursing and health care delivered • Four core concepts 1. Respect and dignity – ensuring that care provided is given based on a pt.’s and family’s knowledge, values, beliefs, and cultural backgrounds 2. Information sharing – health care providers communicate and share information, so patients and families receive timely, complete, and accurate information to effectively participate in care and decision making 3. Participation – pts and families are encouraged and supported in participating in care and decision making 4. Collaboration – demonstrated by health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation and patients who are fully engaged in their health care o Management of patient care ▪ Organization – combine and utilize effective use of time (doing the right things) and efficient use of time (doing things right), approaches any procedure or situation as well prepared as possible ▪ Time management – involve learning how, where, and when to use your time; remain goal oriented and use it wisely; use pt. goals to identify priorities (ex: priority to do list) ▪ Utilization of resources – resources include all members of the health care team, pt. care occurs more smoothly when staff members work together; more help can ensure a more comfortable and safer procedure/environment for the pt. ▪ Evaluation – ongoing task; compares actual patient outcomes with expected outcomes; reveals the need to continue current therapies for a longer period, revise approaches to care, or introduce new therapies o Leadership ▪ Characteristics of effective leader • Effective communicator • Consistent in managing conflict • Knowledgeable and competent in all aspects of delivery of care • Role model for staff • Uses participatory approach in decision making • Shows appreciate for a job well done • Shows appreciation for a job well done • Delegates work appropriately • Sets objectives and guides staff • Displays caring, understanding, and empathy for others • Motivates and empowers others • Is proactive and flexible • Focuses on team development • Ethics o Code of Ethics a set of guiding principles that all members of a profession accept. It is a collective statement about the group's expectations and standards of behavior. The American Nurses Association (ANA) established the first code of nursing ethics decades ago. The ANA reviews and revises the code periodically; but principles of responsibility, accountability, advocacy, and confidentiality remain constant. o Understand, give examples of terms Advocacy Advocacy refers to the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patients, including their right to privacy and their right to refuse treatment. Responsibility The word responsibility refers to a willingness to respect one's professional obligations and to follow through. An example is following an agency's policies and procedures. Accountability Accountability refers to the ability to answer for one's actions. You ensure that your professional actions are explainable to your patients and your employer. Confidentiality Federal legislation known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates confidentiality about and protection of patients' personal health information. The legislation defines the rights and privileges of patients for protection of privacy. Social Networking The online presence of social networks presents ethical challenges for nurses. On one hand social networks can be a supportive source of information about patient care or professional nursing activities. Social media can provide you emotional support when you encounter hardships at work with colleagues or patients. On the other hand, the risk to patient privacy is great. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Issues – quality of life, genetic screening, futile care Quality of life represents something deeply personal. Health care researchers use quality-of-life measures to define scientifically the value and benefits of medical interventions. Quality-of-life measures may take into account the age of a patient, the patient's ability to live independently, his or her ability to contribute to society in a gainful way, and other nuanced measures of quality. Futile Care Difficult emotional and spiritual challenges resulting in moral distress can characterize the management of care at the end of life. The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions the term refers to interventions unlikely to produce benefit for a patient. The concept is slippery when applied to clinical situations. If a patient is dying of a condition with little or no hope of recovery, almost any intervention beyond symptom management and comfort measures is seen as futile. In this situation an agreement to label an intervention as futile can help providers, families, and patients turn to palliative care measures as a more constructive approach to the situation. o Guidelines for ethical decision making Deontology proposes a system of ethics that is perhaps most familiar to health care practitioners. Deontology defines actions as right or wrong on the basis of their “right-making characteristics” such as fidelity to promises, truthfulness, and justice. It specifically does not look at consequences of actions to determine right or wrong. Instead, deontology examines a situation for the existence of essential right or wrong. Deontology depends on a mutual understanding of justice, autonomy, and goodness. But it still leaves room for confusion to surface. • Legal issues in nursing o Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. The Nurse Practice Act of each state defines the scope of nursing practice and expanded nursing roles, sets education requirements for nurses, and distinguishes between nursing and medical practice. o Regulatory law, or administrative law, reflects decisions made by administrative bodies such as State Boards of Nursing when rules and regulations are passed. ▪ An example of a regulatory law is the requirement to report incompetent or unethical nursing conduct to the State 303Board of Nursing. HIPAA o Standards of care are the legal requirements for nursing practice that describe minimum acceptable nursing care. Standards reflect the knowledge and skill ordinarily possessed and used by nurses actively practicing in the profession. o The American Nurses Association (ANA) develops standards for nursing practice, policy statements, and similar resolutions. These standards outline the scope, function, and role of the nurse in practice. o Nursing standards of care are described in the Nurse Practice Act of every state, in the federal and state laws regulating hospitals and other health care agencies, by professional and specialty nursing organizations, and by the policies and procedures established by the health care agency where nurses work o Errors ▪ The best way for nurses to avoid malpractice is to follow standards of care, give competent care, and communicate with other health care providers. You also avoid malpractice by developing a caring rapport with the patient and documenting assessments, interventions, and evaluations fully. ▪ Nurses need to know the current nursing literature in their areas of practice. Know and follow the policies and procedures of the agency where you work. Be sensitive to common sources of patient injury such as falls and medication errors. ▪ Finally, communicate with the patient, explain all tests and treatments, document that you provided specific explanations to him or her, and listen to his or her concerns about treatments. You are accountable for timely reporting of any significant changes in the patient's condition to the health care provider and documenting these changes in the medical record. o ADA ▪ The Americans with Disabilities Act (ADA) of 1990 and as amended in 2008 is a civil rights statute that protects the rights of people with physical or mental disabilities. ▪ The ADA prohibits discrimination and ensures equal opportunities for people with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation. ▪ As defined by the statute and the U.S. Supreme Court, a disability is a mental or physical condition that substantially limits a major life activity, including seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself, and/or working. ▪ Under the ADA employers are required to construe the definition of a person's disability to the maximum intent allowed under the ADA. o EMTALA (Emergency Medical Treatment and Active Labor Act) ▪ This act provides that, when a patient comes to the emergency department or the hospital, an appropriate medical screening occurs within the capacity of the hospital. ▪ If an emergency condition exists, staff must evaluate the patient and may not discharge or transfer him or her until the patient's condition stabilizes. ▪ Exceptions to this provision include if a patient requests transfer or discharge in writing after receiving information about the benefits and risks or if a health care provider certifies that the benefits of transfer outweigh the risks. o Living will ▪ Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. ▪ With this document a patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state. ▪ Living wills are often difficult to interpret and not clinically specific in unforeseen circumstances. o Durable power of attorney ▪ A health care proxy or durable power of attorney for health care (DPAHC) is a legal document that designates a person or people of one's choosing to make health care decisions when a patient is no longer able to make decisions on his or her own behalf. ▪ This agent makes health care treatment decisions on the basis of the patient's wishes o Health care surrogate ▪ In some instances obtaining informed consent is difficult. For example, if a patient is unconscious, you must obtain consent from a person legally authorized to give it on the patient's behalf. Sometimes a patient has legally designated surrogate decision makers through special power of attorney documents or court guardianship procedures. ▪ In emergencies, if it is impossible to obtain consent from the patient or an authorized person, a health care provider may perform a procedure required to benefit the patient or save a life without liability for failure to obtain consent. o Organ donation ▪ An individual who is at least 18 years of age has the right to make an organ donation (defined as a “donation of all or part of a human body to take effect upon or after death”). ▪ Donors need to make the gift in writing with their signature. In many states adults sign the back of their driver's license, indicating consent to organ donation. o Minor child ▪ Ordinarily minors may not consent to medical treatment without a parent. However, emancipated minors may consent to medical treatment without a parent. ▪ Parents are usually the legal guardians of pediatric patients; therefore they typically are the people who sign consent forms for treatment. ▪ Occasionally a parent or guardian refuses treatment for a child. In these cases the court sometimes intervenes on the child's behalf. Courts generally consider the child's ultimate safety and well-being as the most important factors. o Consent ▪ A patient's signed consent form is necessary for admission to a health care agency, invasive procedures such as intravenous central line insertion, surgery, some treatment programs such as chemotherapy, and participation in research studies. ▪ A patient signs a general consent form for treatment when admitted to a health care agency or other health care facility. A patient or the patient's representative needs to sign separate special consent or treatment forms before the performance of a specialized procedure. State laws designate individuals who are legally able to give consent to medical treatment ▪ Informed consent is a patient's agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives, and consequences of refusal. ▪ The person responsible for performing the procedure is responsible for obtaining the informed consent. o Use of restraints ▪ A physical restraint is any manual method, physical or mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to move freely. ▪ The Omnibus Reconciliation Act (1987) includes chemical restraint as a form of restraint. ▪ Restraints can be used (1) only to ensure the physical safety of the patient or other patients, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider ▪ The use of restraints has been associated with serious complications and even death. ▪ You need to know when and how to use and safely apply restraints. • Older Adult o Expected physical changes ▪ With aging, muscle mass decreases, body fat increases, and percentage of body water decreases. This increases the concentration of water-soluble drugs such as morphine given in normal doses. The volume of distribution for fat-soluble drugs such as fentanyl increases. ▪ Older adults frequently eat poorly, resulting in low serum albumin levels. Many drugs are highly protein bound. In the presence of low serum albumin, more free drug (active form) is available, thus increasing the risk for side and/or toxic effects. ▪ A decline of liver and renal function naturally occurs with aging. This results in reduced metabolism and excretion of drugs. Thus older adults often experience a greater peak effect and longer duration of analgesics. ▪ Age-related changes in the skin such as thinning and loss of elasticity affect the absorption rate of topical analgesics. ▪ Aging does not automatically lead to disability and dependence. Most older people remain functionally independent despite the increasing prevalence of chronic disease. Nursing assessment provides valuable clues to the effects of a disease or illness on a patient's functional status. Chronic conditions add to the complexity of assessment and care of the older adult. ▪ Most older people have at least one chronic condition, and many have multiple conditions. The physical and psychosocial aspects of aging are closely related. A reduced ability to respond to stress, the experience of multiple losses, and the physical changes associated with normal aging combine to place people at high risk for illness and functional deterioration. ▪ Although the interaction of these physical and psychosocial factors is often serious, do not assume that all older adults have signs, symptoms, or behaviors representing disease and decline or that these are the only factors you need to assess. You also need to identify an older adult's strengths and abilities during the assessment and encourage independence as an integral part of your plan of care o Expected Cognitive Changes ▪ A common misconception about aging is that cognitive impairments are widespread among older adults. Because of this misconception, older adults often fear that they are, or soon will be, cognitively impaired. ▪ Younger adults often assume that older adults will become confused and no longer able to handle their affairs. Forgetfulness as an expected consequence of aging is a myth. Some structural and physiological changes within the brain are associated with cognitive impairment. Reduction in the number of brain cells, deposition of lipofuscin and amyloid in cells, and changes in neurotransmitter levels occur in older adults both with and without cognitive impairment. ▪ Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes. There are standard assessment forms for determining a patient's mental status, including the Mini-Mental State Exam-2 (MMSE- 2), the Mini-Cog, and the Clock Drawing Test ▪ The three common conditions affecting cognition are delirium, dementia, and depression. o Goals for care of cognitively impaired older adults ▪ Provide a comprehensive assessment to differentiate between a progressive or reversible etiology. ▪ Institute medical measures to correct underlying physiological alterations (e.g., infection, electrolyte imbalances, pain). ▪ Maximize safe function. Keep a routine, encourage activity and mobility, limit choices (e.g., clothes for dressing, what to eat), allow for rest. ▪ Provide unconditional positive regard. Be respectful and provide positive nonverbal communication. ▪ Use behaviors to gauge activity and stimulation. Watch for nonverbal signs of anxiety. ▪ Teach caregivers to listen to the behaviors that show stress (e.g., verbalizations such as repetition). ▪ Make sure that the environment is safe for mobility and promote way- finding with pictures or cues. Try to identify patients who wander and remove the cause (e.g., pain, thirst, unfamiliar surroundings, and new noises). ▪ Promote social interaction on the basis of abilities. ▪ Compensate for sensory deficits (e.g., hearing aids, glasses, dentures). ▪ Encourage fluid intake (make sure that fluids are accessible) and avoid long periods of giving nothing orally. ▪ Be vigilant for drug reactions or interactions; consider onset of new symptoms as an adverse reaction. ▪ Activate bed and chair alarms. ▪ Provide ongoing assistance to family caregivers; educate them in nursing care techniques and inform them about community resources. o Nursing Process ▪ Nursing assessment takes into account three key points to ensure an age- specific approach: (1) the interrelation between physical and psychosocial aspects of aging, (2) the effects of disease and disability on functional status and, (3) tailoring the nursing assessment to an older person. A comprehensive assessment of an older adult takes more time than the assessment of a younger adult because of the longer life and medical history and the potential complexity of the history. ▪ During the physical examination allow rest periods as needed or conduct the assessment in several sessions if a patient has reduced energy or limited endurance. Remember to review both prescribed and over-the- counter medications carefully with each patient. ▪ A patient's sensory changes also affect data gathering. Your choice of communication techniques depends on an older adult's visual or hearing impairments. If an older adult is unable to understand your visual or auditory cues, your assessment data will likely be inaccurate or misleading, leading you to incorrectly conclude that the older adult is confused. When a person has a hearing impairment, speak directly to the patient in clear, low-pitched tones and move to a quiet area to reduce background noise. ▪ When caring for people with visual impairments, sit or stand at eye level and face them. Always encourage the use of assistive devices such as glasses and hearing aids. ▪ Memory deficits, if present, affect the accuracy and completeness of your assessment. Information contributed by a family member or other caregiver is sometimes necessary to supplement an older adult's recollection of past medical events and information about current self-care habits, medication adherence, and history of allergies and immunizations. ▪ Use tact when involving another person in the assessment interview. The additional person supplements information with the consent of the older adult, but the older adult remains the primary source of the interview. ▪ During all aspects of an assessment, you are responsible for providing culturally competent care. Your ability to recognize and process your own Pain biases related to ageism, social norms, and racism affects your ability to provide culturally competent care. • Assessment of pain: o Patient’s expression of pain o Characteristics of pain o Onset and duration o Location o Intensity o Quality o Pattern o Relief measures o Contributing symptoms o Effects of pain on the patient • Factors affecting/influencing pain perception o Physiological ▪ Age, fatigue, genes, neurological function ▪ Fatigue increases the perception of pain and can cause problems with sleep and rest. o Social ▪ Attention, previous experiences, family and support groups, spiritual ▪ Spirituality includes active searching for meaning in situations, with questions such as “Why am I suffering?” o Psychological ▪ Anxiety ▪ Coping style o Pain tolerance ▪ The level of pain a person is willing to accept o Cultural ▪ Meaning of pain ▪ Ethnicity • Pain scales Wong-Baker FACES Scale • Cultural considerations o The meaning that a person associates with pain affects the experience of pain and how one adapts to it. This is often closely associated with a person's cultural background, including age, education, race, and familial factors. Cultural beliefs and values affect how individuals cope with pain. They learn what is expected and accepted by their culture, including how to react to pain. Health care providers often mistakenly assume that everyone responds to pain in the same way. Different meanings and attitudes are associated with pain across various cultural groups. o Culture affects pain expression. Some people believe that it is natural to be demonstrative about pain. Others tend to be more introverted. When a person moves to another country, it is important to know to what extent the individual has assimilated into his or her new home. For example, if several generations of a Hispanic patient's family have lived in the United States, the influence of the Spanish culture may be limited, whereas newly immigrated patients still often embrace their cultural norms. o As a nurse explore the impact of cultural differences on a patient's pain experience and make adjustments to the plan of care. Ask if the patient has had any previous bad experiences with pain management. Work with a patient and family to learn their cultural beliefs, values, and preferences to adequately assess and manage pain. Pain is a biopsychosocial phenomenon. Culture shapes the experience of pain, including its expression and a patient's behaviors, or coping responses. o For example, an individual from a higher socioeconomic group has more resources for managing pain and is more likely to adapt behaviors that will lessen pain. One research study showed that people in the lowest as compared to the highest socioeconomic class were 2 to 3 times more likely to feel disabled through pain. Culture also affects a person's choice of lay remedies, help-seeking activities, and receptivity to medical treatment. Some health care providers undertreat pain because they do not understand the cultural effects on the perception of pain intensity. • Implications for Patient-Centered Care o Use culturally appropriate assessment tools such as tools written in the patient's native language to assess pain. o Assess the patient's health literacy level because this affects your ability to provide appropriate education about pain management and therapies. o Recognize variations in subjective responses to pain. Some patients are stoic and less expressive, whereas others are emotive and more likely to verbalize pain. o Be sensitive to variations in communication styles. Some cultures believe that nonverbal expression of pain is sufficient to describe the pain experience, whereas others assume that, if pain medication is appropriate, the nurse will bring it; thus asking is inappropriate. o Understand that expression of pain is unacceptable within certain cultures. Some patients believe that asking for help indicates a lack of respect, whereas others believe acknowledging pain is a sign of weakness. o The meaning of pain varies among cultures. Pain is personal and related to religious beliefs. Some cultures consider suffering a part of life to be endured to enter heaven. o Use knowledge of biological variations of pain. Significant differences in drug metabolism, dosing requirements, therapeutic response, and adverse effects occur in cultural groups. A wide range of responses is also possible within this group. Therefore assess each patient's response to pain medication carefully. o Develop a personal awareness of your own values and beliefs that affect your responses to patients' reports of pain. • Tolerance & Addiction o Drug tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more effects of the drug over time o Addiction: A primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations • Goals for pain management o Determine with the patient what the pain has prevented the patient from doing. o Then agree on an acceptable level of pain that allows return of function. o For example, for the goal, “The patient will achieve a satisfactory level of pain relief within 24 hours,” possible outcomes are as follows: o Reports that pain is a 3 or less on a scale of 0 to 10 o Identifies factors that intensify pain o Uses pain relief measures safely o Level of discomfort does not interfere with activities of daily living (ADLs). • Patient teaching regarding pain management o Implementation ▪ Pain therapy requires an individualized approach, perhaps more so than any other patient problem. The nurse, patient, and frequently the family are partners in pain management. You are responsible for administering and monitoring therapies ordered by health care providers for pain relief and independently providing measures that complement those prescribed. Generally try the least invasive or safest therapy first along with previously used successful patient remedies. If you question a medical therapy, consult with the health care provider. ▪ Regardless of the therapies chosen, your ability to show compassionate care toward patients has the potential for maximizing their pain control. You can help the patient minimize pain through caring behaviors such as listening, offering a gentle touch, and responding promptly to a pain request. o Health Promotion ▪ When providing pain-relief measures, choose therapies suited to a patient's unique pain experience. Apply guidelines for individualizing pain therapy, including the following: ▪ Use different types of pain-relief measures. ▪ Use measures that patient believes are effective. ▪ Keep an open mind about ways to relieve pain. ▪ Keep trying. When efforts at pain relief fail, do not abandon the patient but reassess the situation. o Maintaining Wellness ▪ Patients are better prepared to handle almost any situation when they understand it. The experience of pain and related therapies are no exception. However, patients with moderate-to-severe pain are not always able to participate in decision making until the pain is controlled at an acceptable level. Once you accomplish this, you can begin teaching. ▪ Health literacy significantly affects a patient's pain experience and understanding of pain-management strategies. Low health literacy poses significant barriers to optimal pain management. In a study of patients with chronic pain, patients with low health literacy were found to have low overall pain medication knowledge and did not know where to find health care professionals to help them with their pain. The patients in the study also lacked knowledge about nonpharmacological approaches to pain management and did not know which nonprescription pain medications could provide pain relief. ▪ Research conducted with patients with chronic back pain and other patient groups provides evidence for why educational materials and approaches must be adapted so they are suited for low–health literacy patients. In addition, combat any cultural norms that may stop patients from talking about pain at all. Stoicism not only potentially obscures dangerous signs about which you should know, but it also denies people the opportunity to use labels as a tool to cope with pain. Help patients who don't have the words to describe their pain find them. Because pain affects physical and mental functioning, holistic health approaches are important interventions for maintaining wellness. Holistic health is an ongoing state of wellness that involves taking care of the whole person: body, mind, spirit, and emotions. To achieve optimal health and well-being, it is necessary to have balance of all of the interdependent elements of the whole person. ▪ Patients actively participate in their own well-being whenever possible. Common holistic health approaches include wellness education, regular exercise, and rest, attention to good hygiene practices and nutrition, and management of interpersonal relationships. When a person develops pain, you can offer nonpharmacological and pharmacological strategies. Several nonpharmacological interventions are nurse initiated. • Non-pharmacologic interventions o Nonpharmacological pain relief interventions ▪ Relaxation, guided imagery ▪ Biofeedback ▪ Distraction, music ▪ Cutaneous stimulation • Massage, transcutaneous electrical nerve stimulation (TENS), heat, cold, acupressure ▪ Herbal Remedies ▪ Reducing pain perception • Evaluation of effectiveness of interventions o Beh aviora l I nd icato rs of Effects of Pain ▪ Vocalizations • Moaning • Crying • Gasping • Grunting ▪ Facial Expressions • Grimace • Clenched teeth • Wrinkled forehead • Tightly closed or widely opened eyes or mouth • Lip biting ▪ Body Movement • Restlessness • Immobilization • Muscle tension • Increased hand and finger movements • Pacing activities • Rhythmic or rubbing motions • Protective movement of body parts • Grabbing or holding a body part ▪ Social Interaction • Avoidance of conversation • Focus only on activities for pain relief • Avoidance of social contacts • Reduced attention span • Reduced interaction with environment • Evaluation of pain is one of many nursing responsibilities that require effective critical thinking. • The patient’s response to pain may not be obvious. • Evaluating the appropriateness of pain medication will require nurses to evaluate patients’ responses after administration. • Patients help decide the best times to attempt pain treatments. Ask patients about tolerance to therapy and the overall amount of relief obtained. If patients state that an intervention is not helpful or even aggravates the discomfort, stop it immediately and seek an alternative. • Pain evaluation includes measuring the changing character of pain, the patient’s response to interventions, and the patient’s perceptions of effectiveness of a therapy Grief - Grief – a normal but bewildering cluster of ordinary human emotions arising in response to a significant loss, intensified and complicated by the relationship to the person or the object loss 1. Normal Grief – common and universal reaction characterized by complex, emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death o Normal feelings: disbelief, yearning, anger, and depression o Coping mechanisms: hardiness, resilience, personal sense of control, ability to make sense of and identity positive aspects after a loss 2. Anticipatory grief – occurs before the actual loss or death occurs, especially in situations prolonged or predicted loss o Gives people time to prepare or complete tasks related to impending death 3. Disenfranchised Grief – when their relationship to the deceased person is not socially sanctioned, cannot be shared openly, or seems of lesser significance o Ex: former spouse, married love, incarcerated person, terminated pregnancy o Ambiguous loss – type of disenfranchised grief, can occur when the lost person is physically present but not psychologically available ▪ Ex: dementia, brain injury 4. Complicated Grief – person has a prolonged or significantly difficult time moving forward after a loss o Person experiences chronic and disruptive yearning for the deceased, has trouble accepting the loss, feels excessively bitter, emotionally numb, or anxious about the future o Occurs more often in those who had a conflicted relationship with the deceased, multiple stresses or losses, mental health issues, or lack of social support o Chronic grief – normal grief response for prolonged periods of time (Inc. years to decades) o Exaggerated Grief – exhibits self-destructive or maladaptive behaviors, obsession, or psychotic disorders (suicide risk is high for these people) o Delayed Grief – unusually delayed or postponed because the loss is so overwhelming that the person must avoid the full realization of the loss (triggered by second loss not as significant) o Masked Grief – persons behavior interferes with normal functioning and person is unaware that the disruptive behavior is a result of the loss - Mourning – the outward social expression of grief and the behavior associated with loss - Types of loss o Loss of possessions/objects: (theft, deterioration, misplacement, destruction) extent of grieving depends on value of object, sentiment attached, and its usefulness o Loss of known environment: (leaving home, hospitalization, new job, leaving rehab unit) occurs through maturational or situation events or by injury/illness ▪ Can threaten self-esteem, hopefulness, or belonging o Loss of significant other (divorce, loss of friend, trusted caregiver, pet) can hurt self-esteem needs o Loss of an aspect of life (body part, job, psychological, physiological function) result in loss of a valued aspect of self, altering personal identity and self-concept o Loss of life (death of family member, friend, co-worker, one’s own death) grieves those left behind, dying people also feel sadness or fear pain, loss of control, and dependency on others Criteria for hospice care, palliative care (pg. 761) • Palliative Care – holistic method to prevent and reduce symptoms promotes quality of life and whole person wellbeing through care of mind, body, and spirit; focuses on the prevention, relief, and reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness o Primary goal – to help patients and families achieve the best possible quality of life o Especially important advanced or chronic illness but can be for any age, diagnosis, time, or setting o Appropriate for patients still receiving aggressive treatment with hope of achieving a cure and for patients who have forgone any life-extending treatment o WHO summarization: ▪ Affirms life and regards dying as normal process ▪ Neither hastens or postpones death ▪ Integrates psychological and spiritual aspects of patient care ▪ Offers a support system to help patients live as actively as possible until death ▪ Enhances the quality of life ▪ Uses a team approach to meet the needs of patients and families o Ex: yoga, acupuncture, massage, aromatherapies, music therapy, mindfulness- based stress- reduction techniques • Hospice Care – for the care of terminally ill patients and their families at the end of life; gives priority to managing a patient’s pain and other symptoms, comfort, quality of life, and attention to physical, psychological, social, and spiritual needs o Eligibility: ▪ Approximately 6 months left to live ▪ Family caregiver to provide care when the patient sis no longer able to function alone ▪ Hospice nurses use therapeutic communication, offer psychosocial care, expert symptoms management, promote patient dignity and self-esteem, maintain a comfortable and peaceful environment, provide spiritual comfort and hope, protect against abandonment or isolation, ethical decision making, facilitate mourning o Available in home, hospital, extended care, and nursing home settings o Built on core beliefs and services: ▪ Pt and family are the unit of care ▪ Coordinated home care with access to inpatient and nursing home beds when needed ▪ Symptom management ▪ Physician-directed services ▪ Provision of an interdisciplinary care team ▪ Medical and nursing services available always ▪ Bereavement follow-up after a pts death ▪ Se for trained volunteers for visitation and support Post mortem care, when autopsy required (pg. 765) • Policies and procedures for after death 1. Requesting organ or tissue donation, performing autopsy, verifying and documenting the occurrence of death, providing safe and appropriate postmortem care • Organ donation o Transplant coordinator or social worker request for organ donation upon death o Life support pts pronounced brain dead can stay on life support only to preserve the vital organs o The family gives or denies consent at the time of death if the deceased has not given previous instruction • Autopsy o Family members give consent o Most cases the coroner determines the need for an autopsy; however, the law sometimes require an autopsy to be performed if death is the result of foul play, homicide, suicide, or accidental causes such as MVA’s, falls, ingestion of drugs, death within 24 hours of hospital admission o Typically, physician asks for family’s permission Cultural considerations for death, dying, post-mortem care (pg.767, 755) • African-American: depends on country of origin and degree of American acculturation, o Presence of extended family groups, including church family are common at time of death o Mourning period relatively short o Memorial service and public viewing prior to burial o Organ donation and autopsy allowed • Chinese: death is regarded as a negative life event and there is no concept of an afterlife o Dead are treated with the same respect as the living and may be buried with food and other artifacts o Members of extended family usually stay with deceased up to 8 hours after death o Oldest son or daughter bathes the body under direction from elder o Organ donation and autopsy are uncommon • Hispanic/Latino: honoring family values and roles is essential o Often use special objects such as amulets or rosary beads, alternative healing practices (folk medicine), and prayer o Grief is expressed openly o Religious and spiritual (catholic) are essential at end of life (death is believed to be the will of God) • Native American: o Traditional Navajos – do not touch the body after death ▪ Care includes cleansing the body, painting the deceased’s face, dressing in clothing, and attaching an eagle feather to symbolize a return home ▪ Dead are buried on the deceased’s homeland • Islamic: body is washed, wrapped, cried over, prayed for, and buried as soon as possible after death o Eyes and mouth are closed, face turned toward Mecca o Muslims of the same gender must prepare the body o Bodies are buried, not cremated o Not likely to agree to autopsy (Islamic people believe in quick burials) o Believed that the soul stays with the body until buried o Organ donation is permissible by some Quran interpretations • Buddhist: believe in afterlife in which human’s manifest in different forms o death is preferred at home, and pts state at TOD is important o usually minimize emotional expression and maintain a peaceful, compassionate atmosphere o male family members prepare the body o recommend not touching the body so deceased has a smoother transition to afterlife • Hindu: o Body is placed on the floor with the head facing north o People of the same gender handle the body after death o No general prohibitions against autopsy o Bodies are cremated after death to purify by fire • Jewish: o If Orthodox Judaism determine if members from the Jewish burial society are coming before preparing the body o Family member often stays with the body until burial (usually occurs within 24 hours of death – but not on the Sabbath) some but not all forms of Judaism avoid cremation, autopsy, and embalming Kubler-Ross stages of dying (DABDA pg. 753) • Denial – person cannot accept the fact of the loss; form of psychological protection from a loss that the person cannot yet bear • Anger – person expresses resistance or intense anger at God, other people, or the situation • Bargaining – person cushions and postpones awareness of the loss by trying to prevent it from happening • Depression – the person realizes the full impact of the loss • Acceptance – the person incorporates the loss into life Factors influencing loss and grief (pg.753-756) • Human development: o Toddlers: cannot understand loss or death but often feel anxiety over the loss of objects and separation from parents ▪ Common expressions: changes in eating and sleeping patterns, bowel and bladder disturbances, increased fussiness o School-Aged: understand the concepts of permanence and irreversibility but do not always understand the causes of a loss ▪ Common experiences: some have intense periods of emotional expression and experience changes in eating, sleeping, and level of social engagement o Young Adults: undergo many necessary developmental losses related to their evolving future ▪ Illness or death disrupts the young adult’s future dreams and establishment of an autonomous sense of self o Middle Adults: major life transitions such as caring for aging parents, dealing with changes in marital status, and adapting to new family roles o Older Adults: the aging process leads to necessary and developmental losses ▪ Some experience age discrimination, especially when they become dependent or are near death ▪ Show resilience after a loss because of their prior experiences and developed coping skills • Personal Relationships: the quality and meaning of the lost relationship influence the grief response o Relationships that are very rewarding and well connected tend to cause for difficulty for the survivor o Grief work is hampered by regret and a sense of unfinished business, especially related members that did not have a good relationship • Nature of the loss: will help understand the effect of the loss on the patient’s behavior, health, and well-being o Encouraging patients to share information about the loss will help you better develop appropriate interventions that meet the individualized needs of your patients • Coping Strategies: coping strategies such as talking, journaling, and sharing their emotions with others may be healthy and effective o They may also be unhealthy and ineffective such as increased use of alcohol, drugs, and violence o Nurses provide support by assessing a patient’s coping strategies, educating about new and healthy strategies, and encouraging use of these strategies • Socioeconomic Status: influences a person’s grief response in direct and indirect ways • Culture: patients and families draw on the social and spiritual practices of their culture to find comfort expressions, and meaning in the experience • Spiritual and Religious Beliefs: provide a framework to navigate, understand, and heal from loss, death, and grief o Hope: a multidimensional concept considered to be a component of spirituality, energizes, and provides comfort to individuals experiencing personal challenges ▪ Gives the person the ability to see life as enduring or having meaning or purpose • Nurse’s care for self Communication/care of patient and significant others (761-763) • Provide psychosocial care: patients often experience anxiety, depression, powerlessness, uncertainty, and isolation o Can feel anguish from unknown surroundings, treatment options, health status, and dying process o Worry or fear is also common in pts and often heightens their perception of discomfort and suffering o Can be alleviated by providing information and benefits/burdens of treatment • Promote dignity and self-esteem: includes a person’s positive self-regard, the ability to find meaning in life and feel valued by others, and treatment of caregivers o Nurses promote by respecting him/her person, attending to their physical appearance, allow them to make decisions, keep pt. and family informed • Maintain a comfortable and peaceful environment: comfortable, clean, pleasant environment helps patients relax, promotes good sleep patterns, and minimizes symptom severity o Consider non-pharmacological interventions (allows family members to be more involved) • Promote spiritual comfort and hope: helping pts make connections to their spiritual practice or cultural community can be useful interventions to allow patients assurance that some aspect of their lies will transcend death o Nursing interventions: be present and provide whole person care o Pts perceive the love of family and friends, faith, goal setting, positive relationships with professional caregivers, humor, and uplifting memories as hope promoting • Protect against abandonment and isolation: many pts fears dying alone, and feel more hopeful when others are near to help them o Nurses need to offer reassurance Nursing diagnoses related to grief/death & dying (pg. 757) • Compromised family coping • Death anxiety • Grieving • Complicated grieving • Risk or complicated grieving • Hopelessness • Pain (acute or chronic) • Spiritual distress Steps for Care of the Body after Death (Box 37-11) • 1. Confirm that the health care provider certified the death and documented the time of death and actions taken. • 2. Determine if the health care provider requested an autopsy. An autopsy is required for deaths that occur under certain circumstances. • 3. Validate the status of request for organ or tissue donation. Given the complex and sensitive nature of such requests, only specially trained personnel make the requests. Maintain sensitivity to personal, religious, and cultural beliefs in this process. • 4. Identify the patient using two identifiers (e.g., name and birthday or name and medical record number according to agency policy). • 5. Provide sensitive and dignified nursing care to the patient and family. o a. Elevate the head of the bed as soon as possible after death to prevent discoloration of the face. o b. Collect ordered specimens. o c. Ask if the family wishes to participate in preparation of the body. Offer to make arrangements for supportive company for the family (patient/family religious leader, spiritual care personnel, or bereavement specialist) during body preparation. o d. Ask about family requests for body preparation such as wearing special clothing or religious artifacts. Be aware that personal, religious, or cultural practices determine whether or not to shave male facial hair. Get permission before shaving a beard. o e. Remove all equipment, tubes, and indwelling lines. Note that autopsy or organ donation often poses exceptions to removal; thus consult agency policy in these situations. o f. Cleanse the body thoroughly, maintaining safety standards for body fluids and contamination when indicated. Comb patient's hair or apply personal hairpieces. o g. Cover body with a clean sheet, place head on a pillow, and leave arms outside covers if possible. Close eyes by gently holding them shut; leave dentures in the mouth to maintain facial shape; cover any signs of body trauma. o h. Prepare and clean the environment, deodorize room if needed, and lower the lights. o i. Offer family members the option to view the body and ask if they want you or other support people to accompany them. Honor and respect individual choices. o j. Encourage grievers to say good-bye in their own way: words, touch, singing, religious rituals, or prayers. o k. Provide privacy and an unrushed atmosphere. Assess family members' need or desire for your presence at this time. If you leave, tell them how to reach you. Sleep o l. Determine which personal belongings stay with the body (e.g., wedding ring or religious symbol) and give other personal items to family members. Document time, date, description of the items taken, and who received them. Save any items that are left behind accidentally and contact family for further instructions. o m. Apply identifying name tags and shroud according to agency policy before transporting the body. Follow safety procedures for body fluid precautions or contamination concerns. o n. Complete documentation in the narrative notes section (see Box 37-9). o o. Maintain privacy and dignity when transporting the body to another location; cover the body or stretcher with a clean sheet. • Stages of sleep – definitions & what happens in each stage o Stage 1: NREM ▪ Stage lasts a few minutes. ▪ It includes lightest level of sleep. ▪ Decreased physiological activity begins with gradual fall in vital signs and metabolism. ▪ Sensory stimuli such as noise easily arouse person. ▪ When awakened, person feels as though daydreaming has occurred. o Stage 2: NREM ▪ Stage lasts 10 to 20 minutes. ▪ It is a period of sound sleep. ▪ Relaxation progresses. ▪ Body functions continue to slow. Arousal remains relatively easy. o Stage 3: NREM ▪ Stage lasts 15 to 30 minutes. ▪ It involves initial stages of deep sleep. ▪ Muscles are completely relaxed. ▪ Vital signs decline but remain regular. ▪ Sleeper is difficult to arouse and rarely moves. o Stage 4: NREM ▪ Stage lasts approximately 15 to 30 minutes. ▪ It is the deepest stage of sleep. ▪ If sleep loss has occurred, sleeper spends considerable part of night in this stage. ▪ Vital signs are significantly lower than during waking hours. ▪ Sleepwalking and enuresis (bed-wetting) sometimes occur. ▪ It is very difficult to arouse sleeper. o REM Sleep ▪ Stage usually begins about 90 minutes after sleep has begun. ▪ Duration increases with each sleep cycle and averages 20 minutes. ▪ Vivid, full-color dreaming occurs; less vivid dreaming occurs in other stages. ▪ Stage is typified by rapidly moving eyes, fluctuating heart and respiratory rates, increased or fluctuating blood pressure, loss of skeletal muscle tone, and increase of gastric secretions. ▪ It is very difficult to arouse sleeper. o NREM, Non rapid eye movement; REM, rapid eye movement. • Functions/ Purposes of sleep o The primary function of sleep is unclear. It contributes to physiological and psychological restoration. NREM sleep contributes to body tissue restoration During NREM sleep biological functions slow. A healthy adult's normal heart rate throughout the day averages 70 to 80 beats/min or less if the individual is in excellent physical condition. However, during sleep the heart rate falls to 60 beats/min or less, which benefits cardiac function. Other biological functions decreased during sleep are respirations, blood pressure, and muscle tone. o The body needs sleep to routinely restore biological processes. During deep slow- wave (NREM stage 4) sleep, the body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. Protein synthesis and cell division for renewal of tissues such as the skin, bone marrow, gastric mucosa, or brain occur during rest and sleep. NREM sleep is especially important in children, who experience more stage 4 sleep. o Another theory about the purpose of sleep is that the body conserves energy during sleep. The skeletal muscles relax progressively, and the absence of muscular contraction preserves chemical energy for cellular processes. Lowering of the basal metabolic rate further conserves body energy supply. o REM sleep is necessary for brain tissue restoration and appears to be important for cognitive restoration and memory. It is associated with changes in cerebral blood flow, increased cortical activity, increased oxygen consumption, and epinephrine release. This association helps with memory storage and learning. o The benefits of sleep on behavior often go unnoticed until a person develops a problem resulting from sleep deprivation. A loss of REM sleep leads to feelings of confusion and suspicion. Various body functions (e.g., mood, motor performance, memory, and equilibrium) are altered when prolonged sleep loss occurs. Changes in the natural and cellular immune function also occur with moderate-to-severe sleep deprivation. o The annual direct cost of sleep-related problems in this country is 16 billion dollars. An additional 50 to 100 billion dollars are spent on indirect costs related to accidents, litigation, property damage, hospitalization, and death. • Factors that affect sleep o Drugs and substances ▪ Hypnotics, Antidepressants/stimulants, alcohol, caffeine, diuretics, Beta- Adrenergic Blockers, Benzodiazepines, Nicotine, Opiates, & anticonvulsants. •