ADPIE

Assessment: deliberate systematic collection of data to determine current and past health
status, including patient’s ability to function and cope. Identification actual or
potential health problems, needed to formulate a nursing diagnosis. Collection and
verification of data

Data Collection:

Subjective data: Information given directly from the patient ( i.e. pts perception
understanding and interpretation of what is happening.

Objective Data: concrete observed and collected information

Sources of data: client ( primary source) family members, medical records

Methods of collection: Health Hx, Interviewing using open ended questioning, Physical exam,
vital signs, diagnostic testing

Purpose
Health Hx
Nursing Dx and care plan
Mange patient problems
Evaluate nursing care

Steps: Collection and verification of data from primary source and secondary
source the analysis of all data as a basis for developing a nursing diagnosis
identifying collaborative problems and developing a plan if pt centered care.

Gather health history

- Biological data
- Chief complaint
- Present health concerns
- Past history
- family history
- review of systems
- patient profile

Cultural considerations: consider health believes, use of alternative

therapies, nutritional habits, relationship with family and personal
comfort zone, perception and reporting,

Physical example: Head to toe, baseline vitals

Diagnosis: a nursing diagnosis is a clinical judgment about individual , family, or

community responses to actual and potential health problems or life processes. It
focuses on a client’s response to a health problem, rather than a physiological event,
complication, or disease.

Critical thinking:
 Decision making steps
- Interpret & analyze data
- cluster findings
- Group signs
- Group behaviors

- Look for defining characteristics: clinical criteria or

assessment findings that support an actual Dx. Clinical
criteria can be either objective or subjective signs and
symptoms, clusters of signs and symptoms, or risk factors that lead to a
diagnostic conclusion.

Approach: Diagnostic reasoning: assessment data

Defining Characteristics: assessment findings
Clinical criteria: signs and symptoms

Components of a nursing Diagnosis:

Problem : Diagnostic label : What is the problem from the nursing

assessment: NANDA
Etiology : Related to factors : what is causing the problem: 4 categories
Pathophysiological, treatment relates, situational (environmental or
personal), Maturational ( age related), something that can be treated by
the nurse, not medical dx
Symptoms: Defining characteristics: objective and subjective data

Planning: Priorities !!! ABC ⇒ Safety ⇒ Maslow

Two step process: Writing measurable outcomes with pt specific goals

developing nursing interventions

Expected outcomes: measurable criteria to evaluate goal achievement

Goal: A broad statement describing a desired change in a client’s condition or
behavior

Outcomes:
S: specific
M: measurable
A: Attainable
R: Realistic
T: Timed

Two types of goals:

- Short term: achieved in one week or less
- Long term: achieved in weeks or months

Nursing interventions: actions used to achieve the desired outcomes/goals

NIC: nursing intervention classification:

- 3 types: independent, dependent, collaborative
- 2 other classifications: direct, along with pt, or indirect, on pt’s behalf
Implementation Phase: action phase, carrying out plan of care

Critical thinking approach:

- Review all NIC
- Review all consequences to nursing Dx
- Determine probability of the consequences
- Determine how this will affect the client

Focus on the set outcomes and goals, continuous assessment of outcomes and goals

Documentation: DAR

D: Data
A: Action (intervention)
R: Response (pt’s response to interventions)

Ethics in Nursing

Autonomy: right to self determination, independence, and freedom of decision, right to

refuse care
Beneficence: Positive action don’t to benefit others, putting their interests above your own
Nonmaleficence: Do no harm
Justice: fairness
Veracity: truthfulness
Fidelity: being true to your word

Ethical Decision Making: Seven Step process

1. Is there an ethical dilemma
2. Gather all relevant data
3. Clarify Values
4. Verbalize the problems
5. Identify possible courses of action
6. Negotiate a plan
7. Evaluate the plan

Preventative ethics:

Advance directives: decisions made by competent individual about their future health care

Living Will: Identifies treatments a person wants or does not want or wants should he or
she become unable to make their own decisions – enforceable by law

Durable power of attorney for health care: A person legally designated to make health care
decisions for an individual who is no longer able to make decisions for themselves

Infection control:

Chain of infection: Must have at least 3 elements

Infective agent
Reservoir
Portal of exit
Means of transmission
Portal of entry
Susceptible host
Inflammation:
Vascular and cellular response
Inflammatory exudate
Tissue repair

Inflammatory response:
Always present with infection
Causes: Heat, Radiation, Trauma, Allergens, Infection
Local response: redness, heat, pain, swelling, loss of infection
Clinical Manifestations: Increased WBC, malaise, Nausea, anorexia, increased pulse,
and respiration, fever

HAIs

Factors:
Rate of contact: # of times a person comes in contact with health care worker
Invasive procedures
Therapy
Length of stay

Two types HAIs

Exogenous infections: MRSA
Endogenous Infection: C. Diff

MRSA:
death caused by sepsis
Occurs from: skin-skin, contact with personal items, contact with infected surface
Risk Factors: immunocompromised, invasive procedures, carrier

C. diff clostridium difficile: spore-forming gram-positive anaerobic bacillus, usually seen

with antibiotic use, c. diff releases several toxins which attack cells and can lead to
death

C. Diff clinical manifestation:

Watery diarrhea (10-15*/ day)
ABD cramping
Fever
Blood and pus in stool
Nausea
Dehydration
Loss of appetite
Weight loss

Risk factors:
Antibiotic exposure
GI surgery
Immunocompromised

Potential complications
Hypovolemia
 Renal failure
Peritonitis: bowel perforation, toxic megacolon
Death

Infection Prevention:

Chain of infection

Asepsis:
Hand hygiene
Standard precautions
Disinfect & Sterilize

Patient education:
Hand hygiene
Personal care products
Cough etiquette
Hygiene
Peri-care

Wound Care:
Prevent and manage infection
Cleanse wound
Removable nonviable tissue
Manage exudate
Maintain the wound in a moist environment
Protect the wound

Pressure ulcers : localized area of tissue necrosis caused by unrelieved pressure that
occludes blood flow to the tissue

Influencing factors
Amount of pressure: if pressure is greater on capillary than normal capillary
pressure it will collapse
- ⇑pressure ⇒ occluded blood vessel ⇒ tissue ischemia ⇒ Tissue death
Length of time pressure is exerted
Ability of tissue to tolerate externally applied pressure

Contributing Factors
Shearing force: pressure exerted on the skin when it adheres to the bed and the skin
layers slide in the direction of body movement
Friction
Excessive Moisture

Pressure Ulcer staging

Stage 1: persistent redness in lightly pigmented skin , skin intact

Stage 2: Partial thickness, loss of epidermis, dermis, or both, presents as an abrasion,
intact or ruptures blister, or shallow crater
Stage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue, down
to but not through underlying fascia. Does not expose bone, tendon, muscle
Stage 4: Full thickness loss can extend to muscle, bone, or supporting structures. Bone
tendon, or muscle may be visible or palpable. Slough, escar, or tunneling may be present
Unstageable: wound covered by eschar, may require debridement
May allow eschar to act as a physiological cover

Possible complication:
Recurrence
Cellulitis
Chronic infection
Osteomylitis

Assessment:
Stage
Percentage
Color
Measurement
Exudate: amount, color, consistency, odor
Surrounding skin condition

Treatment:
Document : size, stage, location, exudate, infection, pain, and tissue appearance
Keep ulcer bed moist
Cleanse with nontoxic solutions
Debride
Use adhesive membrane, ointment, or wound dressing
Good nutrition
Self care and signs of breakdown
Initiate specialty services if needed

Musculoskeletal

Osteoporosis: Chronic progressive metabolic bone disease characterized by

Porous bone
Low bone mass
Structural deterioration of bone tissue
Increased bone fragility

More common in women because …..

Lower calcium intake then men
Less bone mass because of smaller frame
Bone reabsorption begins earlier and accelerates after menopause
Pregnancy and breastfeeding deplete woman’s skeletal reserve of calcium
Longevity increases likelihood of osteoporosis, women live longer than men

Etiology and Pathophysiology

Peak bone mass is achieved before age 20
Bone loss after midlife is inevitable but rate of loss is variable
In osteoporosis bone reabsorption exceeds bone deposition
 Occurs most commonly in spine, hips, and wrist
Many drugs can interfere with bone absorption
Walking is best weight baring exercise

Risk Factors
Female
Increased aging
Family Hx
White or Asian
Small structure
Early menopause
Excess alcohol intake
Cigarette smoking
Anorexia
Oophorectomy
Sedentary lifestyle
Insufficient calcium intake
Low testosterone levels in men

Diagnostics
Hx and physical
Bone mineral density
Change in height is # 1 indicator

Osteopenia is more than normal bone loss but not yet at the level of osteoporosis

Good sources of calcium

Sardines
Milk
Yogurt
Turnip
Spinach
Cottage cheese
Ice cream

Supplement Vitamin D

Delirium vs. Dementia

Delirium: State of temporary but acute mental confusion, common in older adults who have a
short term illness

Develops in three days!!!!!

Acute, sudden, unexpected

Early manifestations
Inability to concentrate
Irritability
Insomnia
Loss of appetite
Restlessness
 Confusion

Later Manifestations
Agitation
Misperception
Misinterpretation
Hallucinations

Manifestations are sometimes confused with dementia and depression

Key distinction is patient with delirium exhibits sudden….

Cognitive impairment
Disorientation
Clouded sesnorium

Dementia:

Syndrome characterized by dysfunction or loss of :

Memory
Orientation
Attention
Language
Judgment
Reasoning

Can manifestations ….
Personality changes
Behavioral problems: agitation, delusions, hallucinations

Alzheimer’s disease: #1 form of dementia, chronic progressive, degenerative disease of the

brain

Age is most important risk factor, family Hx, more common in women

Caused by changes in brain structure and function:

Development of plaques and tangles
Loss of connection between cells and cell death
Leads to brain atrophy

Pathological changes begin 5-20 years before clinical manifestation , progression is

variable ranges 3-20 years

Late stages
Long-term memory loss
Unable to communicate
Can’t perform ADLs
Pt may become unresponsive, incontinent, and require total care

Diagnostics
Dx of exclusion
Comprehensive Pt evaluation
 Brain imaging
Definitive dx can only be made at autopsy

SLEEP

Purpose of sleep
Remains unclear
Physiological and psychological
Maintenance of biological function

Dreams
Occur in NREM and REM
Important for learning, memory, and adaptive to stress

Rest contributes
Mental relaxation
Freedom from anxiety
State of mental, physical and spiritual activity

Sensory

Cataract: cloudy or opaque lens interferes with passage of light causing glare or blurred
vision, 3rd leading cause of blindness

Etiology and Pathophysiology

Age
Blunt trauma
Congenital factors
Radiation and UV light exposure ( Tanning beds)
Long-term corticosteroid use
Ocular inflammation

Senile cataract
Most common
Altered metabolic processes cause
- accumulation of water
- Altered lens fiber structure

Clinical Manifestations
Decreased vision
Abnormal color perception
Glaring of vision

Diagnostic studies
Past medical Hx
Physical examination
Visual acuity
Ophthalmosocy
Slit lamp microscopy
Glare Testing

Glaucoma
A group of disorders characterized by
Increased IOP against optic nerve
Optic nerve atrophy
Peripheral visual field loss

Balance between aqueous production and reabsorption needed for normal level of IOP

Communication

Verbal Communication

Sign language, written, or spoken word

Vocabulary
Denotative and connotative meaning
Pacing
Intonation
Clarity and brevity
Timing and relevance

Nonverbal communication
Body language
Voice quality
Manner, directness, and sincerity
Dress and attire
Visual aids
Personal space
Eye contact
Emotional content
Setting time place
Rhythm and pacing
Attitude and confidence
Agenda
Silence

Actions speak loader then words

Factors influencing communication

Physical and emotional factors
Developmental factors
Sociocultural factors
Gender

Therapeutic communication
Active listening
Sharing observations
Sharing empathy
Sharing feelings
Using touch
Using silence
 Providing information
Clarifying
Focusing
Paraphrasing
Asking questions
Summarizing self-disclosure
Confrontation

Nontherapeutic communication
Asking personal questions
Giving personal opinions
Changing the subject
Automatic responses
False reassurances
Sympathy
Asking for explanations
Approval or disapproval
Defensive responses
Arguing

Respiratory

Physiology of Respiration
Ventilation
Compliance
Diffusion
Oxygen-hemoglobin dissociation
Atrial blood gases
Mixed venous blood gases
Oximetry (finger, nose, toes)
Oxygen delivery

Control of respirations
Chemoreceptors
- central: respond to co2 increase
- Peripheral: respond to decrease O2 levels

Pneumonia: Acute inflammation of the lungs caused by microbial organism, leading cause
of death in the US from infectious disease

Etiology:
Likely results when defense mechanisms become incompetent or overwhelmed
Mucociliary mechanism impairment
Alteration of leukocytes from malnutrition
Immunosuppression from other disease processes
Three ways organisms can reach the lungs: Aspiration, inhalation, and hematogenous
spread

Types of pneumonia:
 Community-Acquired Pneumonia: is defined as a lower respiratory tract infection of
the lung parenchyma with onset in the community or during the first 2 days of
hospitalization

Hospital-Acquired pneumonia: occurs after the first 48 hours of admission and not
incubated at the time of hospitalization

Aspiration pneumonia: Sequela occurring form abnormal entry of secretions or

substances into the lower airway, usually follows aspiration of material from the
mouth or stomach into the trachea and then into the lungs. Usually occurs 48-72 hours
after aspiration

Opportunistic pneumonia: Immunocompromised patients , pts with protein-calorie

malnutrition, patents who are being treated with immunosuppressive drugs, radiation,
chemotherapy, and corticosteroids

Cardiovascular system

Hypertension: Persistent elevation of systolic BP equal to or greater than 140 or diastolic

BP equal to or greater to 90, current use of antihypertensive medication

BP = Cardiac output * systemic vascular resistance

Sutohypertention caused by calcification of veins

Primary hypertension: No identifiable causes

Risk factors
Age
Alcohol
Cigarette smoking
DM
Elevated serum lipids
Excess dietary sodium
Gender
Family Hx
Obesity
Ethnicity
Sedentary lifestyle
Socioeconomic status
Stress

Treatment and Prevention

Lifestyle modifications
- Diet
- exercise
Drug therapy
Patient education
Stress management

Secondary hypertension: Elevated BP with an identifiable cause

Congestive heart failure CHF

Right-sided Heart Failure

The right ventricle loses it’s ability to contract, causing blood to back up into
the body, causing congestion. Blood backs up into the liver, the gastrointestinal tract,
and extremities. the right ventricle becomes to damaged and is unable to pump blood
efficiently to the lungs and left ventricle.

Causes of right-sided heart failure

left-sided heart failure

lung diseases (chronic bronchitis, emphysema).
congenital heart disease
clots in pulmonary arteries
pulmonary hypertension
heart valve disease.

Left Sided Heart failure

The left side of the heart receives oxygenated blood from the lungs and pumps it
into systemic circulation. As the ability to pump blood out of the left ventricle is
decreased, the body does not receive enough oxygen, causing fatigue. the pressure in the
veins of the lung increases causing fluid accumulation in the lungs. Resulting in
shortness of breath and pulmonary edema.

Causes of left-sided heart failure

Alcohol abuse
MI
Cardiac infection
Hypertension
Hypothyroidism
Leaking/narrowing valves

Clinical Manifestations
Abnormal heart sounds (murmur)
Abnormal lung sounds
Edema
Distended neck veins
Hypotrophy of liver
Dysrhythmias
Weight gain

Fluid and electrolytes

Hypovolemia: fluid volume excess: loss of water and electrolytes, as in vomiting,

diarrhea, fistulas, fever, excessive sweating, burns, blood loss, GI suctioning, and
third-space fluid shift, decreases intake (anorexia, nausea, inability to access fluids.
Diabetes insipidus and uncontrolled diabetes mellitus also contribute to a depletion of
extracellular fluid volume.
 Signs and symptoms
Acute weight loss
Decreased skin turgor
Oliguria
Concentrated urine
Weak rapid pulse
Capillary refill time increased
Low CVP
Decreased BP
Dizziness
Flattened neck veins
Weakness
Confusion
Thirst
Increased pulses
Muscle cramps
Sunken eyes

Hypervolemia: fluid volume excess: compromised regulatory mechanism, such as renal failure,
heart failure, cirrhosis, over consumption of sodium containing fluids, fluid shift
(treatment of burns), prolonged corticosteroid treatment, sever stress, and
hyperaldosteronism contribute to fluid volume excess.

Signs and Symptoms

Acute weight gain
Peripheral edema
Ascites
Distended jugular veins
Crackles in the lungs
Elevated CVP
SOB
⇑ BP
Bounding pulse and cough
⇑ respiratory rate

Sodium imbalance (neurological)

Excess: Hypernatremia
Thirst
CNS deterioration
Increased interstitial fluid
Elevated body temp
Swollen dry tongue and sticky mucus membrane
Hallucinations
Lethargy
Restlessness
Irritability
Seizures
 Pulmonary edema
⇑ BP
⇑ pulse

Deficit: Hyponatremia
CNS deterioration

Potassium imbalance: ( cardiac)

Excess: hyperkalemia
V-fib
ECG changes
CNS changes

Deficit: hypokalemia
Bradycardia
ECG changes
CNS changes

Diabetes
Glucose: energy
Two sources:
Food: absorbed into bloodstream, insulin assists glucose into tissues and cells
Liver: Stores glucose as glycogen and releases it when blood glucose levels are
low (gluconeogensis)

Type 1 Diabetes

Risk factors:
Unknown
Family Hx

Type 2 Diabetes

Risk Factors:
Weight: high amounts of fatty tissue causes insulin resistance
Inactivity: Increased weight, exercise uses up glucose, making tissue and cells
insulin sensitive
Family Hx
Race: African American, Hispanic, Native American, Asians
Age: >45yo
Gestational Diabetes
Polycystic ovarian syndrome
HTN
High LDL/HDL

Diabetes PCs

Acute complications
- diabetic ketoacidosis
- Hyperosmolar hyperglycemic syndrome
- Hyperglycemia
 - Hypoglycemia <70 can be fatal because brain needs glucose to function

Chronic complications
- CVD: Atherosclerosis, PVD, cerebrovascular, HTN, dyslipidemia
- Retinopathy: can lead to blindness, also at risk for cataracts and glaucoma
- Neuropathy
- LE complications related to decreased sensation
- Integumentary complications
- Infection

Urinary

24 hour urine specimen collection: Always through away the first urine because you need to
start with an empty bladder, at the end of 24 hours instruct patient to urinate, unsure
that serum creatinine is determined during 24 hour period. keep collected specimen on ice
or refrigerated, 24 hr urine is collected to check clearance of creatinine by the kidneys,
given an estimate of the GFR, Creatinine is a waste product of protein breakdown, primarily
body muscle mass, 12-24 hour urine test may also be done to test for protein in urine, it
is more accurate then dipstick, persistent proteinuria usually indicates Glomeruli renal
disease.

Urinary retention: the inability to empty the bladder completely despite micturition or the
accumulation of urine in the bladder because of inability to urinate. Can be associated
with urinary leakage or post void dribbling, called overflow urinary incontinence.

Acute urinary retention: the complete inability to pass urine via micturition, medical
emergency
Chronic urinary retention: incomplete bladder emptying despite urination.

2000-3000mL of urinary retention is considered a medical emergency.

Normal postvoid residual volume 50-75ml a finding of over 100ml indicates the need to
repeat measurement

An abnormal PVR in an elderly pt is a measurement of > 200ml on two separate occasions

Urinary retention is caused by two different dysfunctions of the urinary system: bladder
outlet obstruction and deficient detrusor contraction strength. Obstruction leads to
urinary retention when the blockage is sufficiently severe so that the bladder can no
longer evacuate its contents despite detrusor contraction. Common cause enlarged prostate.
Deficient detrusor contraction strength leads to urinary retention when the muscle strength
is no longer able to contract with enough force or for a sufficient period of time to
completely empty the bladder. Common causes of deficient detrusor contraction strength are
neurological diseases affecting sacral segment 2,3, and 4; long standing DM, over
distention, chronic alcoholism and drugs.

URINARY TRACT INFECTION: Page 1155 Lewis

Most common bacterial infection in women, Pregnant women are at increased risk. E. coli
most common cause, primarily in women. There are also fungal and parasitic infections but
they are less common

Kidney infections may present as lower back pain.

When an older adult has an UTI it may manifest as confusion!!!!!!

Classification:

Upper urinary tract infection: involves renal parenchyma, pelvis, ureters, typically causes
fever, chills, and flank pain

Lower urinary tract infection: confined to lower urinary tract and usually has no
systematic manifestation

Pyelonephritis: inflammation of the renal parenchyma and collecting system

Cystitis: inflammation of the bladder wall

Urethritis: inflammation of urethra

Urosepsis: UTI that has spread into systemic circulation, a life threatening condition.

Uncomplicated: are infections that occur in otherwise normal urinary tract usually only
involves the bladder

Complicated: are the infections that coexist with obstruction, stones, catheters, diabetes,
neurological disease, pregnancy-induced changes, or an infection that is recurrent.
Patients with complicated UTI’s are at risk for Pyelonephritis, renal damage, and urosepsis

UTI’s can also be classified by their natural history, for example initial infection,
secondary infection, or recurrent

Bodies natural defenses against UTIs

Normal voiding with complete bladder emptying

Ureterovesical junction competence

Peristaltic activity that propels urine towards bladder.

Antibacterial properties of urine (pH<6.0) high urea concentration, and

abundant glycoproteins that interfere with bacterial growth

Menopause and UTIs

Before menopause , glycogen rich epithelial cells and normal flora keep the vaginal pH
acidic (3.5-4.5). In postmenopausal women, lower estrogen levels cause vaginal atrophy, a
decrease and lactobacillus, and a increase in vaginal pH, increasing the risks for a UTI.
Treatment giving women low dose estrogen replacement to acidify the vagina

After seven days on antibiotic therapy pcp my order a repeat UA to check for nitrates to
make sure UTI has been completely eliminated

Urinary Incontinence : an under diagnosed and underreported problem that can significantly
impact the quality of life and decrease independence, and my lead to compromise of the
upper urinary tract. Causes may include cognitive decline, medication and underlying
physical conditions, including UTI and urinary retention
Types:

Stress Incontinence: Most common type, when combined with urge incontinence is
referred to as mixed incontinence, may be caused by poor pelvic muscle strength
leading to possible leakage when laughing, sneezing, coughing. Education on kegal
exercises.
Urge Incontinence: over active bladder is common cause
Reflux Incontinence: leakage with out warning may be caused by neuro defect
Overflow Incontinence: caused by full bladder, possible in ability to urinate,
distention
Functional Incontinence: is caused by loss of cognitive function, environment,
Latrogenic: is an unknown cause
Mixed Incontinence: combination of Stress and Urge incontinence

Problems with fecal incontinence may signal neurological causes for bladder problems
because of shared nerve pathway. Constipation and impaction can partially obstruct the
urethra, causing inadequate bladder emptying, overflow incontinence and infection.

Abnormal UA findings: Ketones, Protein, glucose, nitrates, blood

Fecal incontinence:

Occurs with
Motor and sensory dysfunction
Weakness or disruption of anal sphincters
Nerve Damage
Trauma

Constipation:

Causes:
Insufficient dietary fiber
Inadequate fluid intake
Decreased physical activity
Ignoring the urge to defecate
Medications
Neuro dysfunction
Emotions
Bowel obstruction

Watch for laxative abuse!!!!!

Stress and coping

Stress: is an experience that a person is exposed to through a stimulus or stressor. The

appraisal or perception of a stressor. Stress can also be a link between environmental
demands and a persons perception of those demands as challenging, threatening, or
demanding. People experience stress as a consequence of daily life and stress can be
helpful in stimulating thinking processes and helping people stay alert in their
environment. Stress can facilitate growth and personal development. How people react to
stress depends on how they view and evaluate the impact of the stressor, its effect on
their situation and support at the time of the stressor, and their usual coping methods.

When stress overwhelms a person’s existing coping mechanisms, disequilibrium occurs, and a
crisis results. If symptoms of stress persist beyond the duration of the stressor, the
person has experiences a trauma

Stressors: disruptive forces operating with in or on any system , an event or thing

that has caused an individual stress.
Appraisal: How people interpret the impact of the stressor on them selves, of what is
happening and what they are able to do about it
Suicide: is caused by an inability to cope

Body’s response to stress:

Interrelationship of

Nervous system:
Cerebral cortex: evaluates and plans course of action, theses functions
are involved in the perception of a stressor
Limbic system: mediator of emotions and behavior. When stimulated
emotions, behaviors, and feelings can occur to ensure survival and self-
preservation.
Reticular formation: contains RAS, which sends impulses contributing to
the alertness to the limbic system and cerebral cortex. When stimulated
the RAS increases its output of impulses leading to wakefulness,
overstimulation due to stress can lead to sleep disturbances.
Hypothalamus / Pituitary: fight or flight, stimulated by limbic system,
secretes neuropeptides that regulate the release of hormones by thee
anterior pituitary , is central to the connection between the nervous
system and endocrine system in response to stress.
Endocrine System:
SNS stimulates the adrenal cortex to release epinephrine and
norepinephrine (catecholamines) , which prepare the body for fight or
flight, Endorphins have an analgesic-like effects and blunt pain
perception during stress situations involving painful stimuli,
Corticosteroids are essential for the stress response, they produce a
number of physiological responses including increased blood glucose,
potentiating the actions of catecholamines on blood vessels, and
inhibiting inflammation response. Corticosteroids play an important role
in turning off the stress response , which if left uncontrolled can
become self-destructive.
Immune system:
Brain is connected to the immune system by neuroanatomic and
neuroendocrine pathways, stressors have the potential to lead to
alterations in immune system function. Both acute and chronic stress can
affect immune function, including decreased number and function of
natural killer cells. Chronic stress induces immunosuppression

The increase in cardiac output, increase in blood glucose, increased 02 consumption,

and increased metabolic rate make the stress response possible. Dilation of
skeletal muscle blood vessels increase blood supply to the large muscles and provide
for quick movement, increased cerebral blood flow increases mental alertness, The
increased blood volume (from increased extracellular fluid and the shunting of blood
away from the GI system) helps maintain adequate circulation to vital organs I case of
traumatic blood loss.

Flight or Fight response: arousal of the sympathetic nervous system. Reaction

prepares you for action by increasing heart rate, diverting blood from the intestines
to the brain and strained muscles, increasing blood pressure, respiratory rate, and
increasing blood glucose levels

Neurphysiological responses to stress function through a negative feedback

Structures that control response to stressors:

Medulla oblongata: Controls heart rate, blood pressure, and respirations. Heart
rate increases in response to impulses from sympathetic
fibers and decreases with impulses from parasympathetic fibers

Reticular formation: Small cluster of neurons in the brain stem and spinal
cord, continuously monitors the physiological status of
the body through connections with sensory and motor tracts

Pituitary Gland: Produces hormones necessary for adaption to stress, such as

ACTH, which produces cortisol. Regulates the secretion of
thyroid, parathyroid, and gonadal hormones.

General adaptation Syndrome: When the body encounters a physical demand the pituitary
initiates GAS

Phases of GAS

Alarm - Be Flight or Fight Ready The hypothalamus, adrenal and pituitary glands release
additional hormones into the bloodstream in order for the body to be prepared for action.
Breathing may become rapid and shallow, the liver releases additional glucose into the
blood for energy and your heart rate may rise. The body can activate the alarm stage many
times throughout the day in response to stressful situations.

Resistance - Reacting to Ongoing Stress During resistance, the body is reacting to

continued stress and the requirement to constantly prepare for action by being
alarmed. In this stage of the General Adaptation Syndrome, the body is using stores
of energy, hormones, minerals and glucose. Symptoms such as stomach problems, muscle
pains, fatigues, headaches, insomnia, intestinal problems and eating issues may
present. Acute stress leads to physiologic changes that are important for adaptation

Exhaustion- Weakening of the Immune System This is the body’s response to continued long
term stress. During the exhaustion stage, the body’s immune system may become
weakened or there may be damage or disease to other internal organs. During
exhaustion there is potential for an individual to experience physical illness as the
immune system breaks down. When stress is excessive or prolonged, physiologic
responses can be maladaptive and lead to harm and disease

Pain

Transduction: Noxious stimuli causes cell damage with the release of sensitizing chemicals,
these substances activate noiciceptors and lead to generation of action potential

Transmission: Action potential continues from site of injury to spinal cord ⇒ brainstem and
thalamus ⇒ thalamus to cortex for processing
Perception: Conscious experience of pain

Modulation: neurons originating in the brainstem descend to the spinal cord and release
substances that inhibit nociceptive impulses

Acute/transient pain
Sudden onset
Less then 3 months or time for normal healing to occur
Mild to sever
Generally can ID a precipitating event or illness
Course of pain decreases over time and goes away as recovery occurs
Can progress to chromic pain
Clinical manifestations: ⇑HR,⇑RR,⇑BP, diaphoresis, anxiety, agitation,
confusion, urinary retention

Chronic Pain
Gradual onset
> 3 months
Does not go away
Treatment goals include: control to the extent possible, enhancing function and
quality of life

Factors Influencing Pain

Physiologic
Affective
Cognitive
Behavioral
Sociocultural
Spiritual
Psychological
Cultural

Treatment of pain Principals

1. Follow the principals of pain assessment

2. Every client deserves adequate pain management
3. Base the treatment on pt goals
4. Use multidisciplinary approach
5. Evaluate the effectiveness of all therapies
6. Use both drug/non drug therapy
7. Prevent/manage med side effects
8. Incorporate teaching throughout assessment and treatment

Distraction: redirection of attention onto something away from the pain

Radiating pain: sensation of pain extending from initial site of injury to another part of
the body, pain feels as though it travels down or along body part

Legal

Torts: Three types

Intentional tort: Willful act that violates a person or property
Assault
Battery
False imprisonment
Intentional infliction of emotional distress
Conversion of property- destruction of persons property

Quasi-intentional tort:
Deformation of character: intentionally harmful
slander (spoken)
Libel (written)
Invasion of privacy
Breach of confidentiality: privileged communication DR. Lawyer, priest

Unintentional Tort:
Negligence: failure to act as a reasonable person would
Malpractice: Professional negligence

Informed Consent: an active, shared decision-making process between a provider and

recipient of care, three conditions must be met

1.Adequate Disclosure
Adequate disclosure of the Dx
Nature and purpose of the proposed treatment
Risks and consequences
Probability of success
Availability of alternative treatment

2.Understanding and Comprehension: of the information being provided before receiving

sedating preoperative medication

3. Voluntary consent: patient must not be persuaded or coerced in any way

Death and Dying

Loss: occurs throughout life after attachment forms

Types of Loss:
Grief: is the emotional response to loss
Bereavement: Individual’s emotional response to the loss of a loved one

Physical Manifestations: Occurs when all vital organs cease to function: irreversible
cessation of circulatory and respiratory function or all functions of the brain

Brain Death: cerebral cortex stops functioning or is irreversibly damaged

Coma or unresponsiveness
Absence of brainstem reflexes
Apnea
Assessment by physician

DNR/DNI require physician’s orders and must be renewed, Transport DNI/DNR is separate
Hospice: six months from death, two admission criteria ( pt wants service, 6mths or less to
live)