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400749 - NURSING & HEALTH BREAKDOWN SPRING REVISION

WEEK 1 - PRINCIPLES OF PRE OPERATIVE CARE

Health (1946) is a state of complete physical, mental and social wellbeing and notmerely the absence of disease or infirmity.

Principles of effective learning allows the learner to direct the direct learning process-get to know other peoples perspective

Surgery is defined as the art and science of treating disease, injuries and deformities byoperation and instrumentation. It is performed for the following purposes

PARU Post anaesthetic recovery unit

PERI operative care - intervention to provide care prior to or during and immediatelyafter surgery

PRE operative care the time consent form are sign, assessment and observations are

taken and premedication has been administered.

Intra operative surgical phase Care of the pt during surgery requires carefulpreparation and knowledge of the events that occur during the surgical

procedure.Categories of surgical procedures

Urgency of the procedure

Elective surgery collection base on pts choiceUrgent require prompting

Emergency immediate to prevent life

Degree of risk

Minor less risk / involves minimal alteration in body parts; often designed to correctdeformities.

Major organ transplant or cardiac surgery /involves extended reconstruction oralteration in body part

Reason of surgery

- Diagnostic- diagnos/assess- Currative repair or remove

- Palliave pain relief, make the pt comfortable

- Preventative prevent illness

- Exploration surgical investigation- Cosmetic change personal apperance

Extend of surgery

- Anatomic location body and organ parts- Simple

- Radical

Common surgical suffexis- Supra - above

- Arthro related to the joints

- Myo related to mucle tissue

- Neuro related to nerves

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- Thorac related to chest

- Abdomino related to abdominal

Why is a patient required to be nil by mouth (NBM) prior tosurgery

- so the risk of vomiting and aspirating emesis during the

surgery are reduced.- General anesthetics typically cause slowing ofgastrointestinal peristalsis

- Patients are only allowed to take a sip of water with aspecific medication (anticoagulants, cardiovascularmedications & anticonvulsants)

- Normal mechanisms for controlling fluid and electrolyebalance, inc respiration, digestion, circulation andelimination are disturbed

- Surgical procedure may cause extensive losses of bloodand other body fluids. The surgical stress response

aggravates any fluid and electrolyte imbalance.Why would a patient require bowel preparation prior to surgeryand how would this be undertaken?

- Empty bowel reduces risk of injury to the intestines andprevents contamination of the operative wound in caseas part of the bowel is incised or opened accidentally, orif a colon is planned.

Common surgical suffixesOma - tumour/swellingItis - inflammation (tonsilitis)Oscopy - looking into (gastroscopy)

Ostomy - making an opening (colostomy)Otomy - cutting into (tracheotomy)Plasty - repair/restore (mammoplasty)Orrhophy - repairing part or suturing (herniorrhaphy)Ectomy - removal of (appendictomy)

Preoperative checklist & consent verification

Pre operative medicationBenzodiapines reduces anxiety, induced sedation &

amnesiaOpiates relax discomfort during preoperative procedure

Histamine increase gastric ph, Decrease gastric volumeAnticholinergies decrease oral and resp. secretion and

preventbradycardia (low heart rate)

Antacids increase gastric phSedative relax ptProphylactic prevent infection

Day of surgery

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FastingObservationPreoperative checklistOrdered preparationsTheater attire

Consent form

WEEK 2 - PRINCIPLES OF INTRA OPERATIVE NURSING CARE

INTRAOPERATIVE PHASE - is from the patient is received in the operatingroom until admitted to the recovery room.Phases of interoperative period

Preoperative holding area

Admission to the operating roomIntroduction to anaestheticPositioning for surgerySurgeryTransfer to recovery

Introduction of anaesthesiaGeneral - is a loss of sensation with loss of consciousness, skeletal

muscle relaxation, analgesic andelimination of the somatic, automatic and endocrineresponses, inc coughing, gagging, vomiting and

sympathetic nervous system responsiveness

Regional - is the loss of sensation to a region of the body withoutloss of consciousness when a specific nerve orgroup of nerves is blocked with the administration of alocal anaesthetic (spinal, epidural or peripheral nerveblock)

Local - is the loss of sensation without loss of consciousness. It canbe induced topically or via infiltration intracutaneously(within the skin) or subcutaneously (placed justbeneath the skin)

Concious sendation - (twilight sleep) is a minimal depressed levelof conciousness with maintenance of the patients

protective airway reflexes.- Primary goal is to reduce patients anxiety and discomfort

and to facilitate cooperation- Conscious sedation retains the patients ability to maintain

their own airway and to respond appropriately to verbalcommands, yet achieve a level of emotional andphysical acceptance of a painful procedure (eg. colonscopy)Documentation - Must be complete, accurate & comprehensive

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Potential intraoperative complicationAnaphylaxis - is a severe allergic reaction

- causes hypotension, tachycardia, broncospasm andpossibly pulmonary oedema

Malignant hyperthermia (MH) - is a rare metabolic disease

characterized by hyperthermia with rigity of skeletalmuscles that can result in death. It occurs with peopleexposed to certain anaesthetic agents.

Hypoxia - deficiency in the amount of oxygen reaching to tissueExcessive blood loss bleeding and or haemorrhagingHypothermia - low body temperature to 34*. it is most common

among babies and elderly peopleGerontological considerations - older people demonstrate a unique

responses to medication.- Physiological changes in ageing may alter the pts responsenot only to the anaesthetic, but also to blood and fluid loss

and replacement, hypothermia, pain and the tolerance ofthe surgical procedure and positioning.- Decrease in the ability to communicate, follow directions

due to altered vision or hearing therefore conciseand clear communication is needed.

- Due to decreased ability to perceive discomfort or pressureon vulnerable areas and loss of skin elasticity

Injury-Intraoperative environment - divided into four

Unrestricted, semi restricted, restricted and transitionPrinciple of Intraoperative phases - safety, assessment, accuracy,

communication, documentation, outcomes

Routine social/hand wash routine - 15 to 30 secondsSurgical hand wash routine - 5 minutes after every invasive procedureeg. catheterizingDifferent handover - verbal, written and taped

WEEK 3 - PRINCIPLES OF ASEPSIS

Asepsis - is defined as the absence of pathogenic microorganisms.- It is also refers to practices that keep a patient as free

from organism as possibleTypes of aseptic technique

Clean/medical technique - no touch technique or clean technique- involves procedure use to reduce and prevent the spread

of microorganisms e.g. hand washing, use of PPESurgical technique - involves procedure used to eliminate all

microorganism, incl. pathogens and spores, from anobject or area by creating a sterile field. Such as an area or

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subject is contaminated if touched by any object thatis not sterile.

Sterile technique - involves complete elimination or destruction ofall microorganisms incl. spores it can be done bysteam under pressure ethylene oxide gas (ETO), hydrogen

peroxide plasma and chemicals such as periacetic acid .Disinfection - a process that kills or in actives microorganisms thatwill reduce to acceptable method. Such as, certain bacterialmay survive and germinate which could lead tocontamination therefore care must be taken to ensureall residual are removed prior to use. Alcohol, chlorines,

glutaraldehydes and phenol but can also cause toxic to tissue.

Methods of disinfection/sterilization - Heat/ Filtration/ Chemicaldisinfectants & Antiseptics/ Alcohol

Principle of surgical asepsis - is to ensure maintenance of asepsis- A sterile object remains sterile only when touched by another

sterile object- Only sterile objects may be placed on the sterile field- Sterile objects or field should be kept in view

Additional precaution - dedicated patient equipment- Allocation of private room with an ensuite for the patient- Use of particular filter mask e.g for patients with tb- Use of PPE- Use of Signage e.g. Stop infection control

WOUND - A wound is a disruption of normal anatomical structure &function that results from pathological process beginninginternally or externally to the involved organs. (Harvey, 2005)

Wound classificationSTATUS OF SKIN INTEGRITY

Open - wound involving a break in skin or mucous membranesClosed - wound involving no breaks in skin e.g. part of body being

struck by blunt object e.g. straining or deceleration offorce against body.

Acute -wounds that proceeds through an orderly and timelyreparative process that results in sustainedrestoration of anatomical and functional integrity.

Chronic - wound that fails to proceeds through an orderly andtimely process to produce anatomical and functionalintegrity.CAUSE

Intentional - wound resulting from surgery - surgical incision;

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introduction of needle into body partUnintentional - wound that occurs unexpectedly - traumatic injury;

knife wound, burnSEVERITY OF INJURY

Superficial - wound that involves only epidermal layer of skin

Penetrating - wound involving break in epidermal skin layer, aswell as dermis and deeper tissues or organsPerforating - Penetrating wound in which foreign object enters and

exits an internal organCLEANLINESS

Clean - wound containing no pathogenic organismsClean contaminated - wound made under aseptic conditions but

involving body cavity that normally harboursmicroorganisms. e.g. surgical wounds enteringgastrointestinal, respiratory, genital or urinary tract.

Contaminated - wound existing under conditions in which

presence of microorganisms is likely e.g. open,traumatic, accidental wounds; surgical woundsin which break in asepsis occurred.

Infected - Bacterial organisms present in wound siteColonised - wound containing microorganisms (usually multiple)

DESCRIPTIVE QUALITIESLaceration - tearing of tissue with irregular wound edgesAbrasion - superficial wound involving scraping or rubbing of skins

surface e.g. wound often resulting from fall (skinnedknee or elbow)

Contusion - closed wound caused by blow to body by blunt object:

contusion or bruise characterized by swelling discolorationand pain e.g. bleeding in underlying tissue caused by bluntforce against body part

Inflammatory response - sequential reaction to cell injury. It neutralizesand dilutes the inflammatory agent, removes necrotic materialsand establishes an environment suitable for healing andrepairType of Wound - Clean

Clean contaminatedContaminated

Infected

Wound Assessment - Observed the wound forWound apperance - consistency and amount of drainageApperance of surrounding skinOedemaBleedingColour - serous, purulent, haemoserous (serosanguineous),

sanguineousApproximation of suture line

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Drains/DrainageWound Asessment - Colour, consistency and amount of drainage

Colour can be: Sereous/ Purulent/ Haemoserous/SanguineousType of dressing

Woven gauze sponges - it is absorbent and are especially useful inwounds to draw away the wound exudates.Wet to dry dressing - use in treating wounds that require

debridement.None adherent gauze dressing - such as Telfa are used over

clean wounds. Telfa gauze has a shiny, non-adherentsurface that does not stick to incisions or wound openingsbut allows drainage to pass through to the softenedgauze above.

Self- adhesive, transparent film - acts as a temporary second skinsuch as Opsite, blisterfilm etc.

Purpose of dressing- protect a wound from microorganisms- Aiding haemostasis- promoting wound healing- supporting or splinting wound site- protecting the patient from seing the wound- promoting thermal insulation of the wound surface- providing maintenance of high humidity between the wound and

the dressing

WEEK 4 - PRINCIPLES OF SAFE MEDICATION ADMINISTRATION

Poisons ListSchedule 1 - Poisons of plant that can be dangerous to health/ onlyavailable for practitionersSchedule 2 - Therapeutic use that is available to the public only frompharmacies or for people licensed to sell these poisons.Schedule 3 - Therapeutic use - dangerous or liable to abuse -Schedule 4 - Poisons that are restricted to medical, dental andveterinary prescription or supplySchedule 5 - Poisons of a hazardous nature - available to the public withcaution such as handling, storage & use

Schedule 6 - Available to public - but are more hazardous or poisonousthan does classified under schedule 5Schedule 7 - requires special precaution in manufacture, handling, useand storage or special individual regulations re. labeling oravailability.Schedule 8 - restrictions recommended for drugs of dependence shouldapply.Schedule 9 - Drugs of abuse. The manufacture, possession, sale and use

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are limited to approve medical and scientific research.

SCHEDULE 4 & 8

Schedule 4 - All prescription drugs

- Antibiotics, anti- hypertensives etc.- Appendix D has some retricted drugsSchedule 8 - NARCOTIC ANAELGESICS

- Opium and- Opium derivatives - morphine- Synthetic opium datives - pethidine

Safe Medication Administration- The right Medication- The right Dose- The right patient- The right route

- The right time (within 30 mins)- The right documentation

Drug order: Must include- Pts full name and other identifying particulars- Allergies / adverse reactions- Age and weight (peadiatric pt)- Name of medication- Form- Dose route and frequency- Date of cessation, total number of doses- Only approved abbreviations

Nurses Rights for safe medication administrayion- Legible, clear written drug order- Complete drug order (Dose, Route and dose dispensed)- Correct drug route and dose dispensed- Ready access to current drug info- Policies on Medication Administration- Administer medications safely and to identify problems in the system- The right to stop, think and be vigilant when administering medications.

Patients Rights - Careful assessment- Information- Informed consent

- Safe administration- Supportive (therapy)- No unnecessary medications- The right to refuse a medication

Pharmacotherapeutics -Pharmacokinetics - is a study of how medications enter the body, reachtheir site of action

in sufficient concentration, are metabolized and excreted

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from the body- The movement of the drugs through out the body.- The action ff the administration of a drug such as an

analgesic: its absorption. Distribution, metabolism bythe cells and elimination from the body, mainly by the

kidneys and liver.Pharmacodynamics - is the study of how a drug acts in the body to exertits action and side effect.

DRUGSECOTRIN aspirin

Use - Rheumatoid arthritis, OA, rheumatic diseases requiring long-term analgesia and anti-inflammatory effect; acute rheumaticfever

Contra - Bleeding disorders, gastric haemorrhage, erosivegastritis, active peptic ulcer; children

Prec - Asthma, peptic ulceration; bleeding tendernies; preop;blood donation; renal, hepatic impairment; precnancy,lactation

Adverse - GI haemorrhage, bleeding disorders, skin rash,dizziness, tinnitus, urate changes

Dose - Adults: 1-2 tabs 3-4 times daily swalloed wholeHEPARIN injection

USE - anticogulant (blood thinner) that prevents and treat bloodclots in the veins, arteries, or lungs. It is also used before surgery toreduce the risk of blood

clots. Treatment and prophylaxis of thromboembolic disorders.

Contra - actually and potential haemorrhagic states, threatenedabortion,endocarditis, severe hypertension, GI ulcerative

conditions etc.Prec - neuraxial anaesthesia, spinal puncture, exp traumatic,

repeated IDC etc.Adverse - Haemorrhage, heparin induced thrombosis/

thrombocytopenia syndrome, local skin necrosisDIGOXIN lanoxin (64)

Use - CHF, atrial fibrillation

LANOXIN

Use - CHF , Arterial fibrillationConta - intermittent complete heart block, 66

FRUSEMIDE

Drug Calculation

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Liquid dosageSR/SS x VTablet dosageSR/SS

Volume (ml)/ time(min) x drip factorMacro 20Micro - 40

Unit of metric measurement

- To convert grams to milligrams multiply (x) by 1000 ormove to the decimal point 3 spaces to the right (this alsoapplies to the conversion of milligrams to micrograms)

E.g. 3g (3.0)=1 x 3000mg = 3000mg- To convert milligrams to grams divide (/)by 1000 or move

the decimal point 3 spaces to the left (this also applies tothe conversion of microorganisms to milligrams).

E.g. 3000 = 3000 / 1000 = 3g

Grams Milligram - Microgram Litre - Millilitre1.0g - 1000mg - 1,000,000mcg - 1.0L - 1000ml

Mole amount of substance

Medication management abbreviations

TimesAc before mealsPc after mealsHoursOd once dailyBd twice dailyM (mane) in the morningN (nocte) at nightPrn whenever necessaryStat immediatedlyTds 3 times daily

Qid 4 times dailyQh every hourQ4h every 4 hours1/24 administered hourly2/24 administered every 2 hours1/7 once per day1/12 once per month1/52 once a week

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Form of drugCap capsuleGtt dropsInj injection

Mist mixturePulv powderNeb nebulizerSupp suppositoryTab tabletUng ointment

RoutesIM IntramuscularIV intraveneousNG nasogastric

PO by mouthPR by rectal routePV by the vaginaSC subcutaneousSL sublingualWEEK 5 - PRINCIPLES OF POST OPERATIVE NURSING CARE

Post operative care - begin immediately after surgeryInvolves - assessment, diagnosis, planning, intervention and

outcome evaluation

Goals to prevent complications and promote healing

Return to ward (RTW) - Assessment- Airway - clear, open able to verbalize- Breathing - rate, rhythm & depth, cyanosis (bluishdiscoloration), respiratory noise i.e stridour / wheeze- Colour of mucous membranes and nail beds * Cyanosis &

cap refill *- O2 saturation- Encourage DB & Cough exercise- Circulation - pink, perfused, bleeding

- handover from recovery room ward staff- Safety

- Restless patient, bed rails- Maintain & Assess; IVT, dressing, wounds, drains,

PCAs IDCCardiovascular care

- Assess circulation- Pulse, rate & rhythm

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- BP- Capillary refill- Wound for drainage, swelling, brising- To assess for haemorrhage

- ECG if indicated *

- Encourage- Mobility- Use of TED sequential stockinga

Planning Post Op careAssessment includes

- * Knowledge of A&P? - Disease - procedure - patient-ABC - Vital signs- Resp Status- Pain Status (Gaslow coma scale - aldrate score consiosness , palse. Resp. circulation.

Mobility

- Incision / wound/ dressing- Input & Outputs - IVT, Drainage tubes etc- Body temperature 36 to 37 adult

35.5 to 37.5 child- Routine (4 hourly)

Post Operative Nursing care- Documentation- Wound Assessment- Mobility- Comfort - pressure area care, post op wash- Nausea

- Urine output- NBM by mouth post op- Pre operative education- Hourly obs every 4 hours- Special consideration

- Spiritual / psychological needs- Religion- All domains of health such as:

- psycological-biologicaL-PHYSICOSOCIAL

- ENVIRONMENTAL- SOCIAL CULTURAL

Clinical pathways-A case management system that organises and sequences the care giving

process at the patient level to achieve quality and cost outcomes

Parenteral medication - involves injecting or inhaled type into bodytissue via an

altenative route e.g. through intravenous except stomach and

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oral.

4 Routes for parenteral routes- Subcutaneous (SC) - injection into tissue below the dermis of

the skin eg. insulin, heparin

Intramuscular (IM/IMI) - injection into a muscle eg. pain relief,v vaccination *most effective administration*Intravenous (IV/IVI) - injection into a veinIntradermal (ID) - injection into the dermis immediately below

the epidermis *less effective*

Intramuscular injection sites- Bum Cheeks (Ventrogluteal) - 4mls- Arm (Deltoid) - no more than 2 mls- Thigh (Vastus lateralus)- can inject up to 5 mls

Advantages can be gicven regardless of consciousness of patient,

more rapeidly absorbDisadvantage- localized redness, painful, nerve damage, bleeding, skinirritation, oential nerve damages

Oral routes- SUBLINGUAL administration (SL) - placed under the tongue

todissolved e.g. Glyceryl trinitrate

- Should not be swallowed, as desired effect will notbe achieved

- Pt would not be allowed to drink until medication iscompletely dissolved

- BUCCAL Administration - placing the solid medication inthe mouth against the mucous membranes of the cheeks whereit stays until it dissolves

- Can alternate checks to avoid mucosal irritation- Pt is not allowed to chew or swallow medication or to

take with any liquids- Acts locally on the mucosa or systemically as it is

swallowed in a persons saliva

*DRUG CALCULATION!!!* check 736 fundamentals booksSafe medication administration

The nurse must be aware of the FIVE RIGHTS of themedication administration

1. The right medication2. The right dose3. The right patient4. The right route5. The right time

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WEEK 6 - PRINCIPLES FLUID & ELECTROLYTE MANAGEMENT

Maintain health and function of all body systemA balance (homeostasis) is maintain by

1. Intake and output of H20 and electrolytes2. Hormonal regulation (ADH, aldosterone, renin and angiotensin I)

Daily Fluid Intake and OutputAv. Adult = 2200-2700mls a dayUrine output Formula: 0.5ml - 1ml/kg/hr

Nursing assessment of FVD- Monitor, assess and document accurate intake and output

(FBC)- Assess and document urine output (colour, quantity,

concentration, urine specific gravity -the higher it is themore a pt is dehydrated)

- Monitor and document fluid loss form wound drainage,tubes, diarrhoea, bleeding, vomiting

- Monitor lab results (blood, haematocrit and BUN)- CVP monitoring (low CVP)- Colour , smell

- Glasgow coma scale (15) 12 is serious- Daily weight

Electrolyte imbalances- Hypokalemia - a low potassium level in the blood. This is

likely to be present in dehydration and with theprolonged use of certain diuretics.

- Serum K3.5mEq/L- Signs: Dyshythmias, ECG changes, N&V, anorexia,bowel sounds, ileus, muscle weakness, leg cramps

- Hyperkalema- Serum K5mEq/L- Signs: tall peaked T waves, widened QRS, dysrhythmias,

cardia arrest; N&V, abdominal cramping, diarrhoea;muscle weakness, paresthesias, flaccid paralysis

Distribution of body fluid (4)

- ECF extra cellular fluid Risk oedema LOW ICF hypobolaemia deficit if HIGH ICF

Hyperbolemia

-ICF intra cellular fluid risk hypobolemia-Plasma

-Intertistitial

IV FLUID TONICITYTonicity

1.Isotonic healthy 0.9%

2.Hypotonic expanded 0.45% soduim3.Hypertonic - exploded 5.0%

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FLUID BALANCE EXCESS

- CAUSE BY FLUID OVERLOAD- RESULT WHEN BOTH WATER AND SODUIM ARE RETAINED IN

THE BODY

SIGNs & SYPTOMS

- WEIGHT GAIN- PERIPHERAL OR severe generalized oedema (anasaca)- Full bounding pulse, tachycardia, increase BP- Distended jugular neck vein (icrs. JVP)- SOB (short of breath) etc.

NURSING MANAGEMENT

- Monitor intake and output monitor for physical signs and symptoms of

hypervolemia- weight

- monitor side effects

ELECTROLYTE IMBALANCES

HypokalemiaSerum K5mEq/L

Signs:Tall peaked T waves, widened QRS, dysrhythmias, cardiac arrest; N&V, abdominal

cramping, diarrhoea; muscle weakness, paresthesias, flaccid paralysis

- Loss is not confined to the experience of losing someone through death- Loss is a phenomenon which occurs across the lifespan and is an inevitable part of the

transitions, changes and growth that occur through everyday life- Loss derives meaning from the person experiencing it

Key points- Assess- Monitor- Document

Factors that require assessments-Skin turgor-Mucous membranes

-Dry lips-Jugular veins-Fluid and input and outputPossible complication intravenous therapy-bleeding-Inflamatation of the skin-Skin irritation-pulling out or comes out

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-Redness-swelling

WEEK 7 - PRINCIPLE OF PREVENTING POST OP COMPLICATIONS

- A disease or injury that dev/elops during the treatment of a pre-existing disorder..The

complication often alters the prognosis

- An accident or second disease process arising during the course of or following theprimary condition; can be fataL

- We define the term complication to be a universal term, encompassing both events related

to the disease process and events related to healthcare interventions

Risk factors

- Age

- Nutrition- Obesity- Radiotherapy- Fluid & electrolyte balance- Pregnancy- Medical conditions- Drugs

Complications

- Respiratory- Cardiovascular- Integumantary

Fluid & electrolyte- Neuropsychological- Urinary- Gastrointestinal- Pneumonia- DVT (deep vein thrombosis)- Infected wound healing- Neuropsychological- Urinary infection, retention, renal failure- Gastrointestinal complications- Paralytic Ileus

TED stockings - thrombo embolic device stockingHudsons mask - 6 to 8 litresNasal prongs - 2 to 4 litres

Nebuliser mask - inhaled medication e.g. for asthma

- 8 litresVenturi mask - delivers different litres of oxygen such as use of patient with

emphysema 02 retainers.

Mask 8 litres - orange 50 %

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Mask 4 litres - yellow 31 %

Mask 4 litres - white 28 %

Mask 6 litres - pink

Maxolon nausea and vomiting

Adverse dystonic reaction

Vicrows trial 1. is vennes states2. damages to inner lining of the veins

3. Coagulability (Thinken of the blood)

CAUSES

Changes in blood vessels wallBlood flow

Blob compression

TED stocking

POTENTIAL COMPLICATIONSPE (pulmonary embolism)

CVI (Chronic venous insufficiency)Phlegmanasia cerulean (swollen, blue, and pain full e.g. gangerene)

Secondary to venous abstraction

(pos and neg. amputation)

WEEK 8 - PRINCIPLE OF PAIN MANAGEMENT

- An unpleasant sensory & emotional experience associated with actual or potential tissue

damage, or described in terms of such damage (International Association for the Study of Pain, 2008)

- Pain is whatever the experiencing person says it is, existing when he says it does(McCaffery, 1979)

- Pain is subjective and highly individual (Crisp & Taylor 2009).

Pain perception (pathphysiology)

- The point at which a person is aware of pain- Depends on the functioning of higher brain centres,

therefore, only exists if it is interpreted by the CNS

- Perception gives awareness to pain, after whichPhysiological & behavioural responses follow (signs

& symptoms- Described in terms of pain threshold and pain tolerance.

Pain threshold - refers to the point at which pain is first experienced

- little variation between individuals in terms of pain threshold

Pain tolerance - the point at which an individual reports pain to be so intense that itcan no longer be tolerated

- wide variation in the tolerance, associated with the age, gender,

ethnicity, past experience & other factors.

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Physiological

- Autonomic nervous system stimulated as part the stress response- Flight or fight response- continues

Behavioural Responses to pain

- Vocalisations- Body movements- Facial expressions

Classification of painAcute - short term usually nociceptor

Chronic - long term long lasting pain

Pain managent

- Prevalence of unrelieved pain in hospitalized (inc post-operative)- Studies show similar problems for pt across various care setting

Pain assessment

- Accurate assessment is vital- Many factors can potentially influence the pain experience incl. staff attitudesor action.

- Self report is the indicator of pain severity

ABCDE approach

- Ask about pain regularly - Assess pain regularly- Believe the pt & family in their report of pain and what relieves it- Choose pain control options appropriate for the pt, family setting- Deliver interventions in a timely, logical and coordinated fashion- Empower pt and their family - Enable them to control their course to the

greatest extent possible

PAIN RATING SCALES- measures pain intensity

- Verbal rating scale (VRSs)- category scales consisting of various words e.g. mild or severe

- visual analogie scale (VAS)

-A 10cm line anchored at each end with the words such as no painand the worst pain possible

Pain rating scales - 1 from no pain to 10 worst pain imaginable

Observational charts - recording of behaviours which accompany pain

- medication use- level of function

- non verbal expression - body /face languagePain in children - Assessment of pain in children incl. hx, physical examination,physiological and behavioural measurement and commonly the pain facesscale.

Pain management pharmacological approaches

- Opoids none steroid and anti-inflammatory drugs- Paracetamol -- Local anesthetics

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- Adjuvant- Multimodal analgesia (co - analgesics)- Inhalation e.g. Nitrous Oxide (N2O2)- PCA pt controlled analgesia

- other consideration - addiction- tolerance - physical

dependencePain management NONE pharmacoloical approaches

- Cognitive - behavioural approaches- Acupunctures- Mobilization- arotheraphy

Physical approachesSpinal manual therapy

Mobilization

Application of superficial hear or coldExercise

Trancutaneous electrical nerve stimulation (TENS)

FACTORS WHICH INFLUENCE INDIVIDUALS EXPERIENCE OF PAIN

Physiological consciousness, neurological function , age, gender,

Social social dependant, support network and stressors.Spiritual -/cultural different language, meaning and attitude associated with pain across

various cultural group, meaning of pain belief in high power

Psychological arousal of the non adrenegenic brain. Attention previus expercinceanxiety and coping style

Paracetamol -

Ibuprofen

Morphine sulphateEndone

Tramadol

Diazepam

Fentanyl

WEEKS 10 - PRINCIPLE OF WOUND ASSESSMENT

Skin is the most largest organ of the body

A wound is defined as a disruption of normal anatomical structure & function that resultsfrom pathological processes beginning internally or externally to the involved organ (Crisp

& Taylor)

Inflammatory response - sequential reaction to cell injury. It neutralizesand dilutes the inflammatory agent, removes necrotic materials

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and establishes an environment suitable for healing andrepairType of Wound - Clean

Clean contaminatedContaminated

Infected

Wound Assessment - Observed the wound forWound apperance - consistency and amount of drainageApperance of surrounding skinOedemaBleedingColour - serous, purulent, haemoserous (serosanguineous),

sanguineousApproximation of suture lineDrains/Drainage

Wound Asessment - Colour, consistency and amount of drainageColour can be: Sereous/ Purulent/ Haemoserous/

SanguineousType of dressing

Woven gauze sponges - it is absorbent and are especially useful inwounds to draw away the wound exudates.

Wet to dry dressing - use in treating wounds that requiredebridement.

None adherent gauze dressing - such as Telfa are used over cleanwounds. Telfa gauze has a shiny, non-adherent surfacethat does not stick to incisions or wound openings but allowsdrainage to pass through to the softened gauze above.

Self- adhesive, transparent film - acts as a temporary second skin

such as Opsite, blisterfilm etc.Purpose of dressing

- protect a wound from microorganisms- Aiding haemostasis- promoting wound healing- supporting or splinting wound site- protecting the patient from seing the wound- promoting thermal insulation of the wound surface- providing maintenance of high humidity between the wound and

the dressingColour

- Red - blood is getting their - healing- Yellow - infected- Black - necrotic

Wound healing

Primary intention- Wounds where margins are neatly approximated

- Healing occurs in 3 phases

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1. Initial phase (3 - 5 days)

2. Granulation phase (5 days - 4 weeks)

3. Maturation phase & scar contracture (7 days - several months)Secondary Intention

- Healing of wounds with edges that cannot be approximated

- Healing same as in primary but the inflammatory reaction may be greater- Healing takes place from edges of wound inward & bottom of wound upTertiary intention

- Healing occurs with delayed suturing of the wound- Occurs when:

- Contaminated wound left open & closed once clean- When primary wound infected, is opened, allowed to

granulate then sutured

Conditions for wound healing

- Well being- Nutrition

- Vascular supple/drainage- Clean wound- Minimal trauma- Moist environment- Thermal regulation

Factors that promote wound healing

- Maintain strict asepsis during surgery and the post operative period is thesingle most important factors in promoting wound healing

Factors delayed wound healing

- obesity- debilitation (weakness & mobility)

- advanced age- mechanical friction on the wound- Treatments - steroids, chemotherapy, radiotherapy- Nutritional deficiencies- Presence of disease e.g. diabetes mellitus- Presence of infection- Inadequate blood supply- Poor general health- Impaired oxygenation / Anaemia- Smoking- Wound stress

Signs & Symptoms of impaired wound healingWound infections often evident within 36-48 hrs post op. most appear

within 5 - 7 days

Signs & Symptoms of INFECTION- Increased temperature (swinging heat around wound)- Increase heat around wound- Increase or change in exudates- Increased discomfort

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- General malaise (feeling of a general discomfort illness)Classification Pressure ulcers

Stage I - Intact skin with non blanchable rednessStage II - partial thickness skin loss involving epidermis/ dermis on both

Stage III - full thickness tissue loss with visible fat

Stage IV - full thickness tissue loss with expose bone and muscleStage V un stagable or necroticPredicting & preventing pressure ulcers

Risk assessment:

- Hygiene and skin care- Positioning- Support services

Norton scale

Water scaleBraden scale

Factors affecting pressure ulcer healing- Shearing- Friction- Moist- Nutritional status- Anemia- Cachecxia (a condition of extreme debility)- Obesity- Infection- Impaired peripheral circulation- Age

Nursing process assessment- Predictive measures- Skin- Mobility- Nutritional status- Pain- Patient expectations- Wound appearance- Character of wound drainage- Drains- Wound closure

- Palpation of wound- Wound cultures- Observe the wound for - Appearance of the wound and surrounded skin

- oedema- bleeding

- colour

- approximation suture line

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- monitor drains

- Colour, consistency and amount of drainage

- Colour can be:- Serous- cleae watewry plasma

- Purulent think, yello gren and brown

- Haemoserous (serosanguineous) pale, red watery and mixed obboth serosanguinoues and sangeinous

-Sanguineous bright red , indicated heavy bleeding

- Assess the wound for signs of infection- Inflammation

- Drainage (increased ooze from wound)

- Odour

- Pain- Induration (hardened tissue)

- Take a wound hx by asking - cause

- when

- what was the initial size- what were the changes

Nursing Process intervention

- Nursing intervention to promote improved skin integrity and / or woundheaing

- Consult health professionals such as nutritionist and wound carespecialist

- Involve the pt and family in using interventions- Dressing- Purposes of dressing- Types of changes

- Changing dressings- Packing a wound- Securing dressing- Pain management- Clean skin and drain sites- Suture care- Drainage evacuation- Bandages- Planning education- Further of wound care- Signs and symptoms of manifestation of infection

- Nutritional / dietary instructions- Position e.g. elevation of requiredWound heals

AIR acute inflammation response

GranulationMaturation

Repair

Remodeling

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Factors to wound care age

Older peoples wound healing is impaired, more suseptable to infection and impared

circulation to wound site. Lower immune responseComplications of wound healing

Haemorhage, wound dihescence, ecisceration, fistula formation- delayed closure

WEEKS 11 - PRINCIPLE OF GRIEF & LOSS

Loss - experience of losing someone through death or losing other things that you can

never bring back

Types of lossActual death of someone

Perceived belief of a loss

Maturation -

Situational understand the situationCategories of loss

Loss of

- external objects- Known environment- Significant other- Aspects of self- Life

Terms associated with loss

- Bereavement experience of suffering loss usually of a loved one, bydeath or separatition, that can also include the loss of previous good

health- Grief emotional and physical responses- Mourning - the same as bereavement *after the death*

Manifestations

- Physical- Behavioural- Cognitive- Emotional- Spiritual

Factors determining response to grief- Personality

- Relationship & attachment to deceases- Mode of death- Personal experiences and age- Cultural and religious variables

Grief response: complications- Physical conditions- Social isolation- Clinical depression

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- Suicide and threats of suicide yearsDifferences across the lifespan

Childhood

- Infant- Older infant

- 5 - 7Adolescence- Egocentric- Highly romantic ideas- Individual personalities determine behaviours

Adulthood

- Young - intense emotional about imminebt death- Middle - know eventually going to die, reassess career, marriage,

relationship

- Late - Come to terms with mortality, already lost friends & family,Recognise, reorganize thoughts about death

Managing Grief: clinical setting- Establish rapport - Reassurance / support / Empathetic understanding / l

Listening

- Spiritual/cultural support

- Formal counseling- Support groups

Nurses:

- Debriefing- Short break/time out

- Preparation or not) of deseace body for transfer to mortuary

- empty bed

- Attending pts funeral- other : spiritual, counselling

Cd4T

Documents

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