NCLEX-RN: Nursing Concepts

Nursing Concepts: THE AGED

Focus topic: Nursing Concepts

Nursing Concepts: Developmental Tasks

Focus topic: Nursing Concepts

✦A. Maintains ego integrity versus despair.

  • Integrity results when an individual is satisfied with his or her own actions and lifestyle, feels life is meaningful, remains optimistic, and continues to grow.
  • Despair results from the feeling that he or she has failed and that it is too late to change.

B. Continues a meaningful life after retirement.
C. Adjusts to income level.
D. Makes satisfactory living arrangements with spouse.
E. Adjusts to loss of spouse. (Forty-five percent of women older than age 65 are widowed.)
F. Maintains social contact and responsibilities.
G. Faces death realistically.

H. Provides knowledge and wisdom to assist those at other developmental levels to grow and learn.
I. In the year 2010, there were approximately 40 million people older than age 65 in the United States.

Nursing Concepts: Physiological Changes

Focus topic: Nursing Concepts

A. Decrease in ability to maintain homeostasis.

  • Decrease in physical strength and endurance.
  • Decrease in muscular coordination and strength.

B. Changes in bone composition.

  • Loss of density and increased brittleness.
  • Increased spine curvatures.

C. Tendency to gain weight.
D. Loss of pigment in hair and elasticity of skin.
E. Diminution of sensory faculties.

  • Vision decreases.
  • Loss of hearing occurs.
  • Smell and taste become dull.
  • Greater sensitivity to temperature changes occurs with low tolerance to cold.

F. Lowered immune system—decreased resistance to infection and disease.
G. Degenerative changes in the cardiovascular system.

  • Heart pump action diminishes.
  • Blood flow decreases—may be due to fat deposits in arteries.
  • Vascular changes result in less effective oxygenation.

H. Changes in respiratory system.

  • Blood flow decreases to lungs: Contributes to decrease in function.
  • Less oxygen diffusion so tolerance is less.

I. Changes in gastrointestinal system.

  • Absorption function impaired.
    a. Body absorbs less nutrients.
    b. Decrease in gastric enzymes affects absorption.
  • Peristalsis weakens and constipation is common.

J. Changes in urinary system.

  • Structural and functional changes occur in kidney through degeneration.
  • Decreased musculature ability leads to atonic bladder.

Nursing Concepts: Major Health Problems

Focus topic: Nursing Concepts

A. All systems are more vulnerable because of the aging process; degeneration can be affected.

  • Chronic disease and disability.
  • Nutritional deprivation; dehydration.
  • Sensory impairment—blindness and deafness.
  • 4. Organic brain changes.
    a. Not all persons become senile.
    b. Most people have memory impairment.
    c. The change is gradual.

B. Impact of disease on aged.

  • Diseases may be multiple and chronic (more than 40% have more than one illness concurrently).
  • Disability results more readily when an aging person becomes ill.
  • Response to treatment is diminished.
  • Resistance is lower due to the aging process so the person is more susceptible to disease.
  • The aged have less resistance to stressors—mental, environmental, and physical.
  • Changes in the neurological system make aged persons more prone to organic brain changes.
  • Many elderly take numerous medications and are susceptible to drug reactions and side effects.

Nursing Concepts: Psychosocial Changes

Focus topic: Nursing Concepts

A. Developmental process retrogresses.

  • Exhibits increasing dependency.
  • Concerns focus increasingly on self.
  • Displays narrower interests.
  • Needs tangible evidence of affection.

B. Major fears of the aged.

  • Physical and economic dependency.
  • Chronic illness.
  • Loneliness.
  • Boredom resulting from not being needed.

✦C. Major problems of the aged.

  • Alteration in living style (e.g., nursing home,
    moving in with children).
  • Economic deprivation.
    a. Increased cost of living on a fixed income.
    b. Increased need for costly medical care.
  • Chronic disease and disability.
  • Social isolation/loneliness.
  • Sensory deprivation (blindness and deafness).
  • Senility, confusion, and lack of awareness.
  • Nutritional deprivation.
  • Series of losses (e.g., relationships, friends, family).
  • Loss of physical strength and agility.

D. Sexuality and aging.

  • Older people are sexual beings.
  • There is no particular age at which a person’s sexual functioning ceases.
  • Frequency of genital sexual behavior (intercourse) may tend to decline gradually in later years, but capacity for expression and enjoyment continue far into old age.
  • Touching and companionship are of importance for older people and should be encouraged.

Nursing Concepts: Cultural Sensitivity

Focus topic: Nursing Concepts

A. Demographic shifts influence the direction of health care.

  • In the United States, 29% of the population are people of color and more than 12% are of Hispanic origin.
  • In 2010, there were more than 40 million
  • These statistics create barriers to health care.
    a. The major barrier is language.
    b. The other barriers are poverty, poor nutrition,
    and poor prevention practices.
  • Reduced access to health care is a major problem for non–English-speaking peoples.foreign-born Americans and 34 million did not speak English.

B. It is important for nurses to understand the impact of various cultures on healthcare practices.
C. Cultural diversity implications.

  • Differences in values, beliefs, customs, folklore, traditions, language, and patterns of behavior.
  • Other aspects of differences are personal space related to culture, gender, and group behavior.

Nursing Concepts: CULTURAL BELIEFS

Focus topic: Nursing Concepts

Nursing Concepts

Nursing Concepts: RELIGIOUS DIVERSITY CONSIDERATIONS

Focus topic: Nursing Concepts

Nursing Concepts

D. Cultural assessment—important to include in a complete client assessment.

  • Cultural background and orientation.
  • Communication patterns.
  • Nutritional practices.
    a. Cultural/religious beliefs that do not eliminate whole food groups (Table 3-5).
    b. Beliefs that interfere with receiving a healthy, balanced diet (such as a macrobiotic diet).
    c. Food practices that do not allow foods to lose all nutrient value during preparation (overcooking vegetables).
  • Family relationships.
  • Beliefs and perceptions related to health, illness, and treatment.
  • Values related to health.
  • Education.
  • Issues affecting healthcare delivery.

Nursing Concepts: The Grieving Process

Focus topic: Nursing Concepts

Nursing Concepts: ✦ Stages of Grief

Focus topic: Nursing Concepts

Definition: A process that an individual goes through in response to the loss of a significant or loved person. The grieving process follows certain predictable phases—classic description originally defined by Dr. Eric Lindeman. The normal grieving process is described by George Engle, M.D., in “Grief and Grieving,” American Journal of Nursing, September 1964.

A. Shock and disbelief: First response is shock and refusal to believe that the loved one is dead.

B. Developing awareness: As awareness increases, the bereaved experiences severe anguish.

  • Crying is common in this stage.
  • Anger directed toward those people or circumstances thought to be responsible.

C. Restitution: Mourning is the next stage where the work of restitution takes place.

  • Rituals of the funeral help the bereaved accept reality.
  • Support from friends and spiritual guidance comfort the bereaved.

D. Resolution of the loss: Occurs as the mourner begins to deal with the void.

E. Idealization: Negative feelings are repressed and only the pleasant memories are remembered.

  • Characterized by the mourner’s taking on certain qualities of the deceased.
  • This process takes many months as preoccupation with the deceased diminishes.

✦F. Outcome of the grief process takes a year or more.

  • Indications of successful outcome are when the mourner remembers both the pleasant and unpleasant memories.
  • Eventual outcome influenced by:
    a. Importance of the deceased in the life of mourner.
    b. The degree of dependence in the relationship. The amount of ambivalence toward the deceased.
    ✦c. The more hostile the feelings that exist, the more guilt that interferes with the grieving process.
    d. Age of both mourner and deceased.
    e. Death of a child is more difficult to resolve than that of an aged loved one.
    ✦f. Number and nature of previous grief experiences. Loss is cumulative.
    g. Degree of preparation for the loss.

Nursing Concepts

Nursing Concepts: Counseling Guidelines

Focus topic: Nursing Concepts

✦A. Recognize that grief is a syndrome with somatic and psychological symptomatology.

  • Weeping, complaints of fatigue, digestive disturbance, and insomnia.
  • Guilt, anger, and irritability.
  • Restless, but unable to initiate meaningful activity.
  • Depression and agitation.

B. Be prepared to support the family as they learn of the death.

  • Know the general response to death by recognizing the stages of the grief process.
  • Understand that the behavior of the mourner may be unstable and disturbed.

C. Use therapeutic communication techniques.

  • Encourage the mourner to express feelings, especially through crying.
  • Attempt to meet the needs of the mourner for privacy, information, and support.
  • Show respect for the religious and social customs of the family.

D. Recognize the difference between grief and loss.

  • Grief is the emotion experienced in response to loss.
  • When one is grieving, he or she is feeling all of the emotions that accompany loss.
    a. Grief is not one emotion, but a combination of feelings.
    b. Grief encompasses all of the initial feelings of loss and moves through the stages to resolution.

Nursing Concepts: Death and Dying

Focus topic: Nursing Concepts

A. The dying process is described in On Death and Dying, by Elisabeth Kübler-Ross, New York, Macmillan Publishing Company, Inc., 1969.

✦B. Stages of dying.

  • Denial: Individual is stunned at the knowledge he or she is dying and denies it.
  • Anger: Anger and resentment usually follow as the individual questions, “Why me?”
  • Bargaining: With the beginning of acceptance of impending death comes the bargaining stage—that is, bargaining for time to complete some situation in his or her life.
  • Depression: Full acknowledgment usually brings depression; individual begins to work through feelings and to withdraw from life and relationships.
  • Acceptance: Final stage is full acceptance and preparation for death.

C. Throughout the dying process, hope is an important element that should be supported but not reinforced unrealistically.

D. Psychosocial clinical manifestations—behaviors and reactions the nurse will expect to observe in clients who are going through the dying process.

  • Depression and withdrawal.
  • Fear and anxiety.
  • Focus is internal.
  • Agitation and restlessness.

Nursing Concepts: The Concept of Death in the Aging Population

Focus topic: Nursing Concepts

A. In American culture, death is very distasteful.
B. Older adults may see death as an end to suffering and loneliness.
C. Death is not feared if the person has lived a long and fulfilled life, having completed all developmental tasks.
D. Religious beliefs and/or philosophy of life is important.

Nursing Concepts: Death and Children

Focus topic: Nursing Concepts

✦A. Understanding of death for the young child.

  • Death is viewed as a temporary separation from parents, sometimes viewed synonymously with sleep.
  • Child may express fear of pain and wish to avoid it.
  • Child’s awareness is lessened by physical symptoms if death comes suddenly.
  • Gradual terminal illness may simulate the adult process: depression, withdrawal, fearfulness, and anxiety.

B. Older children’s concerns.

  • Death is identified as a “person” to be avoided.
  • Child may ask directly if he or she is going to die.
  • Concerns center on fear of pain, fear of being left alone, and fear of leaving parents and friends.

C. Adolescent concerns.

  • Death is recognized as irreversible and inevitable.
  • Adolescent often avoids talking about impending death, and staff may enter into this “conspiracy of silence.”
  • Adolescents have more understanding of death than adults tend to realize.

Nursing Concepts: Nursing Management

Focus topic: Nursing Concepts

✦ Nursing Management of the Dying Adult

Focus topic: Nursing Concepts

A. Minimize physical discomfort.

  • Evaluate pain as the fifth vital sign.
    a. Alleviate client’s pain according to orders—be the client’s advocate for pain relief.*
    b. Explore all options (drugs and alternative therapy) for achieving pain relief.
  • Attend to all physical needs.
  • Make client as comfortable as possible.

B. Recognize crisis situation.

  • Observe for changes in client’s condition.
  • Support client.

C. Be prepared to give the dying client the emotional support needed.

D. Encourage communication.

  • Allow client to express feelings, to talk, or to cry.
  • Pick up cues that client wants to talk, especially about fears.
  • Be available to form a relationship with client.
  • Communicate honestly.

E. Prepare and support the family for their impending loss.
F. Understand the grieving process of client and family.

✦ Nursing Management of the Dying Child

Focus topic: Nursing Concepts

A. Always elicit the child’s understanding of death before discussing it.
B. Before discussing death with child, discuss it with parents.
C. Parental reactions include the continuum of grief process and stages of dying.

  • Reactions depend on previous experience with loss.
  • Reactions also depend on relationship with the child and circumstances of illness or injury.
  • Reactions depend on degree of guilt felt by parents.

D. Assist parents in expressing their fears, concerns, and grief so that they may be more supportive to the child.
E. Assist parents in understanding siblings’ possible reactions to a terminally ill child.

1. Guilt: belief that they caused the problem or illness.
2. Jealousy: demand for equal attention from the parents.
3. Anger: feelings of being left behind.

Nursing Concepts: Pain Management

Focus topic: Nursing Concepts

✦ Characteristics

Focus topic: Nursing Concepts

A. Pain now considered the fifth vital sign—must be assessed regularly (The Joint Commission) to maintain client’s quality of life.
B. The experience of pain.

  • Pain source—direct causative factor.
  • Stimulation of pain receptor—mechanical, chemical, thermal, electrical, or ischemic.
  • Pain pathway.
    a. Sensory pathways through dorsal root, ending on second-order neuron in posterior horn.
    b. Afferent fibers cross over to anterolateral pathway, ascend in lateral spinothalamic tract to thalamus.
    c. Fibers then travel to postcentral gyrus in parietal lobe.

Nursing Concepts: Theories of Pain

Focus topic: Nursing Concepts

A. Specificity theory—certain pain receptors are stimulated by a type of sensory stimulus that sends impulses to the brain.
B. Pattern theory—pain originates in spinal cord and results in receptor stimulation coded in central nervous system (CNS) and signifies pain.
C. Gate control theory.

  • Pain impulses can be modulated by a transmission-blocking action within CNS.
  • Large-diameter cutaneous pain fibers can be stimulated (rubbing, scratching) and may inhibit smaller diameter excitatory fibers and prevent transmission of that impulse.
  • Cerebral cortical mechanisms that influence perception and interpretation may also inhibit transmission.

D. Endorphins—the brain produces natural brain opioids that fit (lock) into special receptors. Antilocks, called antagonists, keep endorphins from working.

Assessment

Focus topic: Nursing Concepts

✦A. Assess for type of pain.

  • Acute—localized, shorter duration, sharp sensation. Occurs over defined period—6 months or less.
  • Chronic pain—long duration, diffuse, dull aching quality; associated autonomic responses, musculoskeletal tension, nausea. Occurs over 6-month period or longer.
  • Malignant—recurrent, acute episodes; also includes chronic varying in intensity—lasts longer than 6 months.
  • Psychogenic—due to emotional factors without anatomic or physiological explanation.

B. Assess onset of pain.
C. Assess location, where it originates and travels.
D. Evaluate intensity and character of pain.

  • Select a tool based on client’s preferences and cognitive abilities.
  • Examples of pain scales—verbal descriptor, numeric rating, FACES, and pain thermometer.

E. Quality—searing, dull, sharp, throbbing.
F. Pattern—timing.

G. Check precipitating factors.
H. Assess associated factors.

  • Nausea and/or vomiting.
  • Bradycardia/tachycardia.
  • Hypotension/hypertension.
  • Profuse perspiration.
  • Apprehension or anxiety.

I. Assess duration of pain.
J. Evaluate previous experience of pain.

Nursing Concepts

Nursing Concepts: Implementation

Focus topic: Nursing Concepts

A. Assess pain before treating.
B. Give reassurance, reduce anxiety and fears.
C. Offer distraction.
D. Give comfort measures: Positioning, rest, elevation, heat/cold applications; protect from painful stimuli.
E. Massage nonsurgical area of pain—but never massage calf due to danger of emboli.
F. Administer pain medication as needed: Monitor therapeutic, toxic dose and side effects.
G. Monitor alternative methods to control pain.

  • Dorsal column stimulator: stimulation of electrodes at dorsal column of spinal cord by client-controlled device to inhibit pain.
  • Analgesics: Alter perception, threshold, and reaction to pain.
  • Anesthesia: Block pain pathway.
  • Local nerve block.
  • Neurosurgical procedures: interrupt sensory pathways; usually also affect pressure and temperature pathways.
    a. Neurectomy: Interrupt cranial or peripheral nerves.
    b. Sympathectomy: Interrupt afferent pathways (ganglia).

Nursing Concepts

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