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Nursing Process: why does Nursing need its own process?

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Identifying a process for our own profession *assists in clarifying the scope of our practice * identifies what is unique to our practice *facilitates dialogue in provision of interdisciplinary patient care

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Steps of Nursing Process

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-Assessment -Nursing Dx -Outcome identification -Planning -Implementation -Evaluation

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Assessment

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- systematic collection of subjective and objective data -goal = make clinical nursing judgement about indiv, fam or community -physical, psychological, emotional, sociocultural and spiritual factors considered for total client situation appraisal

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Who is your primary source in an assessment?

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the client

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Who is you secondary source?

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family significant others healthcare workers health records literature review

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What should the assessment include

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Observation Interviewing Examining the client Interpreting laboratory data, diagnostic data

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why is the assessment/ initial database so important?

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= reference point for all further nursing assessments and is crucial in determining plan of care.

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Outcome identification must be

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- measurable -realistic -client focused

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Rationale of interventions

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Must know why you are providing every intervention that you provide

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Somatic

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well localized; stabbing, aching, throbbing; damage to skin, bone, muscle; peripheral nociceptors.

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Visceral

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poorly localized; dull, aching, crampy, referred; injury to organs; nociceptors in skin.

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Neuropathic

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can follow nerve path; sharp, shooting, burning; injured or dysfunctional PNS or CNS; aberrant somatosensory processing

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Nociceptive pain

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-Damage to somatic or visceral tissue -Surgical incision, broken bone, or arthritis -Usually responsive to opioids and nonopioid medications *Somatic *Visceral

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Somatic Nociceptive pain

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Localized Arises from bone, joint, muscle, skin, or connective tissue Somatic pain often is categorized as superficial or deep. Superficial pain arises from skin, mucous membranes, and subcutaneous tissues, and often is described as sharp, burning, or prickly. Deep pain is often characterized as deep, aching, or throbbing and originates in bone, joint, muscle, skin, or connective tissue.

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Visceral Nociceptive pain

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*Tumor involvement or obstruction *Arises from internal organs such as the intestine and bladder *Comes from the activation of nociceptors in the internal organs and lining of the body cavities (ex: the thoracic and abdominal cavities). *Visceral nociceptors respond to: * inflammation * stretching *ischemia. *Stretching of hollow viscera in the intestines and bladder that occurs from tumor involvement or obstruction can produce intense cramping pain.

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Neuropathic Pain

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*Damage to peripheral nerve or CNS *Numbing, hot-burning, shooting, stabbing, or electrical in nature *Sudden, intense, short-lived, or lingering Common causes of neuropathic pain: - trauma -inflammation -metabolic disease: DM, infections of NS, tumors, toxins, and neurologic disease such as MS. *Neuropathic pain often is not well controlled by opioid analgesics alone. Treatment is typically augmented with adjuvant therapies

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Acute pain

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Improves over time Usually less than 3 months Mild - Severe Serves as a warning Anxiety Common

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Chronic pain

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*Worsens and intensifies with the passage of time *Usually greater than 3 months *Moderate - Severe *Serves no purpose *Frustration common

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T/F: Increase in vital signs are an indication that the patient is experiencing pain.

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Vital signs may increase for brief periods of acute pain, but this may not occur in patients with chronic pain. Besides pain, an increase in VS can signal many other problems, such as anxiety or deterioration in the patient's clinical status

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Manifestations of pain

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*Physiologic responses *Increased blood pressure *Increased heart rate *Increased respiratory rate *Neuroendocrine and metabolic responses

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T/F: Depression is common in patients who have chronic pain

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True. Many patients with chronic pain suffer from depression; as a patient group, they have an increased risk of suicide. A long period of pain coupled with deterioration in the patient's functional ability and relationships can cause a situational depression that affects pain relief, rest and interpersonal relationships.

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Assessment of Client Experiencing Pain

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*Subjective data -Normal pattern identification: Location, intensity, quality, and temporal pattern of pain *Objective data -Physical assessment -Diagnostic tests and procedures *Functionality -Measure how chronic pain is effecting life

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Pain Assessment tool for patients 12 y and older who are able to self report:

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*The Numeric Rating Scale (NRS) *For patients 12 years or older. *Patients are asked to rate their pain on a scale of 0-10. *0 represents no pain and a 10 represents the worst pain possible.

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Pain Assessment tool for patients between 3 and 12 yo who are able to self report:

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*The FACES scale (0-10) (The Modified Wong-Baker) *For patients over the age of 3 who are unable to comprehend the Numerical Rating Scale. *The Bieri Faces Scale-Revised is used by Radiation Oncology in the pediatric population.

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Pain Assessment of patients who are able to self report but unable to use other tools

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The Verbal Descriptor Scale (VDS) May be used in place of the NRS when patients are unable to provide a number to describe pain intensity. The following words may be used to quantify pain: no pain, mild, moderate, severe, very severe, or worst possible pain. This scale may be converted to the corresponding numbers on the WILDA Pain Assessment Guide for documentation.

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WILDA pain assessment

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The WILDA© pain assessment guide is used for patients who are able to self-report pain. This guide includes the following elements: *Words to describe pain *Intensity *Location of pain *Duration of pain (continuous, intermittent) *Aggravating and alleviating factors

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FLACC

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5 categories: 0-2 points- higher score is better *Face (expression?) *Legs (position) *Activity (lethargic?) *Cry *Consolability

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OLD CART pain assessment

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Onset Location Duration Characteristics Accompanying symptoms Radiation Treatment (what makes it better) or "Time"

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Pain assessment of patient unable to self-report

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*Premature Infant Pain Profile (PIPP) -For neonates in the NICU per department guidelines *Neonatal Infant Pain Scale (NIPS) -For newborns in the nursery and up to one month of age. -A score greater than 3 indicates pain *Face, Legs, Activity, Cry, Consolability Observational Tool (FLACC) *Used in ages one month to 18 years for procedural/surgical and acute pain.

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Pain Management Reassessment Requirements

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-Ongoing pain reassessment is required to evaluate the changing nature of pain and to determine the response to treatment. -Reassessment of pain intensity is done a minimum of every 4 hours, or more often as warranted by the patient's condition. -Following an intervention for relief of pain, a reassessment of pain intensity should be done within one hour

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Non-Pharmacologic Psychological Nursing Interventions for Pain

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Cognitive-behavioral therapy Relaxation Meditation Hypnosis Music therapy Biofeedback

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Non-Pharmacologic Complementary Modalities Nursing Interventions for Pain

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Traditional Chinese medicine Acupuncture Hypnosis Therapeutic message Aromatherapy

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GFR

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According to the National Kidney Foundation, normal results range from 90 - 120 mL/min/1.73 m2. Older people will have lower normal GFR levels, because GFR decreases with age.

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BUN

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10-20 mg/dL

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Cr

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0.5/0.6-1.1/1.2mg/dL females

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Bolus or loading dose

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One-time dose of medication that may be given at the start of a PCA infusion or can be given as an additional dose to supplement PCA therapy

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Basal or continuous rate

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The amount of medication automatically infused per hour

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Incremental or PCA dose

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The amount of medication infused when the patient presses the control button

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Lockout or delay time

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. Of time that must pass between the completion of one PCA dose and the initiation of the next

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Patient controlled analgesia PCA

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Delivery of opioids via an electronic pump which enables the patient to self administer small doses usually IV at frequent intervals maintaining blood levels of opioids within an effective range

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PCA by proxy

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Unauthorized administration of a PCA dose by anyone other than the patient such as family members caregivers clinicians

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PCA therapy verification of orders

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The physicians order should contain the following: *name and strength of drug (mg/ml or mcg/ml *Bolus or loading dose (mg or mcg) * Basal or continuous rate (mg/he or mcg/hr) *Incremental or PCA dose (mg or mcg) *lockout or delay time (min) *monitoring instructions (respiratory rate sedation pain intensity etc.)

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Two RNs must verify and document orders and PCA pump settings when

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-Initiating the PCA infusion -accepting patient from another floor -changing shift -changing any settings (dose, concentration)

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Suitable candidates for PCA

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Patients with pain who are mentally alert and able to comprehend and to comply with instructions and procedures regarding it's use

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Patients who may not be suitable candidates include

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-Infants and young children -patients with altered mental status -patient with decreased level of consciousness -patients who are not psychologically stable -patients without intellectual capacity to understand and operate the PCA

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PCA side effects

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Nausea and or vomiting Itching urinary retention constipation

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PCA pt at increased risk for respiratory depression

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-pt receiving other sedating drugs (benzodiazepines, antibiotics, and antihistamines) -renal or hepatic insufficiency leading to potential delayed excretion of narcotics -respiratory problems sleep apnea, depressed mental status, or metabolic disease -greater than 65 years old or debilitated -obesity; a dose that is based on total body weight rather than lean body mass can lead to a relative overdosage

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PCA complications; emergency respiratory depression

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If respiratory rate less than eight per minute or sedation level of one not able to arouse: "less then eight intubate" -stop infusion -administer naloxone 0.1mg IV STAT -May repeat every 3-5 minutes x three doses to a total of 0.4mg

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Epidural analgesia

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Method of regional anesthesia that involves the administration of medications as a single injection or a continuous infusion via an epidural pump into the epidural space. The epidural space is a potential space that lies superficial to the Dura mater surrounding the spinal cord

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Neuromotor blockade

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unwanted side effects of epidural anesthesia from local anesthetics that is characterized by muscle weaknessmales)

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Maintenance of epidural catheter insertion site

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-Reinforced dressing as needed monitor site for redness swelling tenderness drainage -report drainage if other than serosanguinous or greater than the size of a silver dollar to physician -Report unusual findings to physician

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Safety concerns for epidural patients

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Patients on anticoagulants are at risk of bleeding into epidural space so should not be on anticoagulants and epidural concurrently Monitor patients for neuromotor blockade. These side effects can cause significant weakness with position changes and ambulation: At risk for falls All patients must ambulate initially with assistance

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PCA and EPCA patient documentation

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The nurse is responsible to document the following on the appropriate patient information record: -RR and sedation level everyone 1 hr x 4 hours, then every 2 hours -pain intensity every four hours -Side effects/complications -evaluation of patient response to interventions

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PCA and EPCA documentation on IV/Epidural PCA & Controlled Substance

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Medication and PCA settings at initial set up, shift change, patient transfer, change in settings; to nurse criteria for all these times Start of infusion container and wasting of unused medication The number of PCA button demands/deliveries and the total amount of medication used every four hours. After recording these amounts clear the four hour shift total to reset the pump for the next four hour total

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Sympathetic blockade

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Sympathetic nerve fibers are responsible for several physiologic parameters including vascular tone. Blockade of the sympathetic fibers with local anesthetics especially in lower extremities can lead to vasodilation this may make a patient prone to low blood pressure especially if partially dehydrated or elderly

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