Fundamentals of Nursing: Pain

Pain is sometimes referred to as the fifth vital sign. Use a numeric pain scale to identify the patient’s pain level. Pain can signify that something is wrong; therefore it is important to identify and treat at once. Pain can be acute or chronic. Medicate pain as prescribed. It is important to maintain comfort for the patient and assess pain throughout the shift. Pain medications are ordered based on the patient’s diagnosis and severity. There are five major types of pain:

  • Acute pain: New onset, lasting a short time and usually affecting one area.
  • Chronic pain: Experienced over a long period of time; it is constant and persistent.
  • Neuropathic pain: Caused by damage to the peripheral nerves.
  • Phantom pain: Postamputation, patient can feel pain in the extremity.
  • Nociceptive pain: Pain in the muscles or joints.

Methods of pain relief may include medications, relaxation, and touch. Pain medications ordered can be narcotics or nonnarcotic analgesics. A PCA (patient-controlled analgesic) may be ordered for patients postoperatively to better control pain. It is important to identify where the patient is having pain, have the patient use either the numeric or the FLACC (Face, Legs, Activity, Cry, Consolability) scale to rate the pain, and document.

SKIN INTEGRITY AND IMMOBILITY

Focus Topic: Fundamentals of Nursing

Immobility is defined as the loss or lack of movement of the legs or arms or both. This can have various causes such as paralysis, bedridden patients who have lost the ability to walk, or surgical procedures that require the patient to stay in bed. When a patient is confined to one position, complications can arise. Complications such as pressure ulcers, blood clots, and contractures of the extremities are the most common. Nursing interventions for the immobile patient are:

  • Turning and repositioning the patient every 2 hours
  • Maintaining proper skin care; applying lotion or barrier cream to affected areas
  • Ensuring proper hydration by increasing the patient’s fluid intake and encouraging him or her to drink water, or through intravenous fluids
  • Performing range of motion (ROM) to increase mobility and decrease the risk of contractures of the muscles
  • A specialty mattress, such as an air mattress, may be ordered for the patient.
  • A wound care consult may also be needed for complex wounds

Fundamentals of Nursing: Common Complications of Immobility

Ulcers

You will be responsible for memorizing and identifying the stages of skin breakdown and healing. Patients who are immobile, especially elderly patients, are at risk for pressure ulcers. A pressure ulcer is a sore that occurs in the skin, causing damage to various layers as a result of constant pressure exerted on one area of the body. Pressure ulcers are classified into four stages based on severity. Refer to your textbook for a visual; you will be tested on the different stages. Ulcers commonly occur on bony prominences such as the coccyx, heels, elbows, hips, and ankles. This is caused by shearing, tension, and friction on the skin. As a nurse, your responsibility is to prevent pressure ulcers by repositioning the patient every 2 hours, applying barrier creams, maintaining dressing changes, and providing adequate hydration. The four stages of pressure ulcers are:

Stage I: Reddening of the skin on the epidermal layer. Skin is intact.
Stage II: Reddening and edema of the epidermis and dermis layer. Similar to a blister. Skin is blanchable.
Stage III: Injury to the subcutaneous layer. Fat may be visible but bones, tendons, or muscles are not exposed.
Stage IV: Severe damage to all layers of the skin with exposed bone, tendon, or muscle.

A visual of these stages will give you a better understanding. A wound care consult may be needed. Dressings such as Duoderm or Aquacel may be needed. Refer to your class notes and your textbook for pictures of different positioning that is used for patients.

Deep Vein Thrombosis

Poor circulation and blood flow resulting from immobility can lead to thrombus formation in the veins and arteries. The most common place for a clot to develop is in the calf. Symptoms of a blood clot are warmth at the site, pain, swelling, and redness. An ultrasound is used to determine whether a clot is present. Patients who are immobile are placed on venous thromboembolism (VTE) prophylactics such as thromboembolism-deterrent (TED) compression stockings or a sequential compression device (SCD) to prevent blood clots. The patient may also be placed on an anticoagulant (blood thinner) such as heparin or Lovenox to decrease the risk for clots. Do not place SCDs or TEDS on the leg with blood clots; this can cause the clot to travel or move. The key is anticoagulation is dissolving the clot before it moves through the vein or artery or becomes larger in size.

It is the nurse’s responsibility to maintain skin integrity and avoid complications in the immobile patient. When taking care of elderly patients who are immobile, use careful measures when turning and repositioning due to fragile skin and weakness. Report any changes in skin to your instructor.

Fundamentals of Nursing: Wound Care

A part of maintaining skin integrity is performing proper wound care and dressing changes. It is important to examine and dress the wound based on the physician’s orders. When a wound is present, you must first take a picture and obtain an exact measurement of the wound. It is important to maintain a clean and sterile environment for any open wounds. Once a sterile field is in place, clean the wound with either normal saline or sterile water, using gauze to clean in and around the wound bed. The type of dressing used will depend on the wound; the most common type is wet to dry. Check the doctor’s orders to see if packing of the wound is needed. Packing involves inserting small strips of gauze, usually ¼ inch wide, into the wound. Cover the wound with a 4-inch by 4-inch gauze and tape. Use only sterile surgical equipment when changing a dressing. At times, the physician may order ointments such as Santyl (collagenase) to be applied to the wound bed for further treatment. A Duoderm or Aquacel dressing to be placed over the wound may also be ordered. When undressing a wound, throw away the old dressing in a red contamination bag, and change gloves when applying a clean dressing. Document that the new dressing was completed. In severe cases, a wound vac is used for continuous drainage of the wound through suction, which is used for a series of days and is only temporary.

OXYGENATION

Focus Topic: Fundamentals of Nursing

Oxygenation involves the amount of oxygen flow to the tissues. I am going to let you in on a little secret, probably the most important piece of advice you will receive during nursing school: Assessing a patient’s respiratory status is always a priority. When a patient is experiencing any respiratory abnormalities, difficulty breathing, shortness of breath, or labored breathing, you need to assess and treat immediately. On exams and tests, when any questions have to do with assessing an airway or treating a patient who has difficulty breathing, the answer always is: Assess the airway first! Oxygen saturation is used to determine the amount of oxygen perfusion through the body. The normal values are 96% to 100%. Keep in mind that a patient with a respiratory disorder may require oxygen.

Common Respiratory Disorders:

  • Chronic obstructive pulmonary disease (COPD)
  • Asthma
  • Pneumonia/bronchitis

Fundamentals of Nursing: Alterations in Breathing Patterns

Normal respirations are usually 12 to 20 per minute.

  • Tachypnea: A rapid increase in respirations to anything above 22 respirations per minute. It is caused by fever, asthma, hyperventilation, anxiety, or pain. Patients present with fast and labored breathing.
  • Bradypnea: Slow respirations of less than 12 breaths per minute. It is caused by pain medication or happens when a patient is sleeping.
  • Kussmaul breathing: Deep and rapid breaths are usually seen in patients who are experiencing metabolic acidosis (excess acid in the tissues) and can be caused by chronic kidney disease or diabetic ketoacidosis.
  • Cheyne–Stokes breathing: Very deep and shallow breaths. Commonly seen in patients with congestive heart failure and in terminally ill patients, as well.

Respiratory Diagnostics

When a patient is experiencing a change in respiratory status, it is important to obtain the correct labs and exams to determine the cause. Diagnostics such as complete blood count (CBC), chest x-ray, arterial blood gases, pulse oximetry, sputum culture, computed tomography angiography (CTA) of the chest, and many others may be used to help diagnose and treat respiratory disorders.

 

Fundamentals of Nursing: Nursing Intervention

When a patient is experiencing a change in respiratory status, first assess the airway and oxygen saturation. Call for help from either the respiratory therapist or team on the floor. Call the doctor for orders. If the patient is experiencing shortness of breath, place the patient in semi-Fowler’s position (an upright sitting position with the head of the bed elevated greater than 45°). Administer oxygen as ordered. A nasal cannula is commonly used to supply oxygen to the patient. When placing the nasal cannula, set the amount to 2 L, and adjust it per physician’s order. In an emergency situation, the patient may require a mask that supplies a larger amount of oxygen.

There are nonemergent nursing interventions that you can perform to facilitate breathing without a physician’s order. Chest physiotherapy (Chest PT) is used to break up secretion in the chest so the patient can better expel the secretions. This is performed by cupping the hands and beating gently on the patient’s upper back. Giving the patient an incentive spirometer (IS) helps the patient expand the lungs and alveoli. Instructing the patient to take deep breaths and cough every 2 hours can help prevent hospital-acquired disorders such as pneumonia. Nebulizer treatments and steroids may also be needed for the patient.

An early sign of a lack of oxygen is a change in mental status and low oxygen saturation levels, and a late sign is clubbing of the nails.

 

ACID–BASE IMBALANCES

Focus Topic: Fundamentals of Nursing

Oxygen saturation level is determined by arterial blood gas (ABG) results—in other words, the amount of oxygen that is flowing in the arteries. The acid–base levels are based on pH, CO2, PaCO2, O2, PaO2, HCO3, and H. Changes in these levels cause acid–base imbalances. When a patient’s respiratory status is impaired, ABGs must be obtained to determine accurate readings. ABGs can be obtained only by a physician or a respiratory therapist using what is called an Allen’s test. I know this may be difficult to grasp at first, but with a little practice, you will be able to identify the imbalances. It is important to know the normal values in order to identify the imbalance. Respiratory disorders such as COPD, asthma, or upper respiratory infections can cause imbalances.

Blood Gas Values:

  • pH: 7.35–7.45
  • PaCO2: 35–45 mmHg
  • PaO2: 80–100 mmHg
  • HCO3: 22–26 mEq/L

Fundamentals of Nursing: Changes in Acid–Base Balance

Respiratory Acidosis

In this condition, PaCO2 is increased above 45 mmHg and pH is decreased (below 7.45). Respiratory acidosis can be caused by obstructive pulmonary diseases, pneumonia, hypoventilation, and asthma. Symptoms are rapid/shallow respirations, confusion, and hypoxemia. Nursing interventions are to maintain the patient’s oxygen saturation levels and airway, and treat the underlying cause. Mechanical ventilation may be needed.

Respiratory Alkalosis

In this condition, PaCO2 is decreased and pH is increased. Respiratory alkalosis is caused by hyperventilation and stress. Symptoms are muscle twitching, deep/rapid breathing, dizziness, tingling of the fingers, and difficulty breathing. Nursing interventions treat the underlying cause and use a rebreathing mask.

Metabolic Acidosis

In this condition, both pH and HCO3 are low. Metabolic acidosis is caused by renal failure, diarrhea, diabetes, vomiting, and shock. Symptoms are fruity breath, nausea, Kussmaul breathing, vomiting, diarrhea, headache, and increased potassium. Nursing interventions are to administer intravenous sodium bicarbonate and maintain respiratory status. Ensure proper nutrition and adequate hydration. Monitor potassium levels.

Metabolic Alkalosis

In this condition, pH and HCO3 are increased. Metabolic alkalosis is caused by vomiting, excessive intake of antacids, and gastric suctioning. The symptoms are tingling, irritability, confusion, tetany, decreased respirations, and muscle cramping. Potassium is also decreased. Nursing interventions are to administer IV fluids, monitor electrolytes, increase potassium, and treat the underlying cause.

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Fundamentals of Nursing

 

Understanding acid–base imbalances was a challenge when I was taking this course. Study groups were definitely very helpful. Memorizing this chart will help you match the imbalance with the corresponding values. Online, you can find many acronyms for the imbalances—try to Google acid–base imbalances.

FLUIDS AND ELECTROLYTES

Focus Topic: Fundamentals of Nursing

Hydration is the key to keeping the body fluid and electrolytes balanced. When electrolytes are imbalanced, symptoms such as tachycardia, muscle cramping, or arrhythmias may occur. Electrolytes include sodium, potassium, magnesium, calcium, and phosphorus. Memorize the lab values for electrolytes because you will need to know them for the rest of your nursing career. I know what you are thinking: “Oh, man, more things to remember.” Yes, more things to remember. It seems like a lot now, but once you become familiar with the values, it will get easier. As a nurse, you will find there are little cheats on the computer that will give you the lab values, so it does get easier. In school, there are no little cheat sheets, so you must memorize! I will describe each electrolyte in detail for you step by step. Let’s begin, shall we?

Electrolyte Lab Values:

  • Potassium (K): 3.5–5.0 mEq/L
  • Sodium (Na): 135–145 mEq/L
  • Magnesium (Mg): 1.5–2.6 mg/dL
  • Phosphorus (P): 2.7–4.5 mg/dL
  • Calcium (Ca): 8.6–10.4 mg/dL

Here is a little secret: The most tested electrolytes are potassium and sodium. Remember all of the lab values, but concentrate and understand K and Na. In the following section, we describe the imbalances.

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Fundamentals of Nursing: Fluid Imbalances

Dehydration/Hypovolemia

Dehydration or hypovolemia is a loss of fluid volume. Causes of dehydration are poor nutrition or fluid intake, surgery, diarrhea, renal disease, vomiting, NGT suctioning, and diuretics. Patients may present with symptoms of increased HR, decreased BP, poor skin turgor, weight loss, low urine output, dizziness, and weakness. Treatment for dehydration is to increase oral intake and to administer intravenous fluids. Monitor intake and urine output.

Fluid Overload/Hypervolemia

An excess of fluid is called hypervolemia. Too much fluid can cause edema (swelling in the intravascular space), typically seen in the lower extremities and ankles, or crackles in the lungs. Hypervolemia can be caused by renal disease or congestive heart failure. Symptoms include crackles in the lungs, edema (swelling in the body), bounding pulse, weight gain, increased BP, and shortness of breath. Treatment consists of administering a diuretic such as furosemide (Lasix), discontinuing all intravenous fluids, decreasing fluid intake, monitoring strict intake and output, monitoring daily weights, and cardiac monitoring.

Fundamentals of Nursing: Potassium Imbalances

Hypokalemia

In this condition, the potassium level is below 3.5 mEq/L. Hypokalemia can be caused by vomiting, diarrhea, gastric suctioning, kidney disease, and diuretics. Symptoms include irregular pulse, heart arrhythmias, muscle weakness, and muscle cramping. Treatment includes administering oral potassium, and intravenous fluids with potassium. Oral potassium is very bitter, so mix in a cup of orange juice to mask the taste. Cardiac monitoring is necessary. Patients with hypokalemia usually have an EKG pattern with a depressed U wave. IV potassium is mixed with saline given only at a slow rate, over the course of two or more hours. Never push IV potassium, because it tends to burn and cause discomfort. Monitor the patient’s kidney status closely before administering potassium.

Hyperkalemia

Here, potassium levels are above 5.0 mEq/L. Hyperkalemia is caused by kidney disease, and medications such as angiotensin-converting enzyme (ACE) inhibitors are common causes. Symptoms include slow HR, weakness, cardiac arrhythmias, abdominal cramping, and muscle twitching. A peaked T wave may appear on the EKG; this cardiac arrhythmia can be fatal and must be treated immediately. Treatment includes decreasing potassium in the diet and administering sodium polystyrene (Kayexalate), a medication that decreases potassium in the blood.

Fundamentals of Nursing: Sodium Imbalances

Hyponatremia

In this condition, sodium levels are below 135 mEq/L. Hyponatremia is caused by fluid overload, edema, diuretics, burns/ wounds, and administration of an excess amount of D5W. Symptoms include headache, confusion, abdominal cramping, muscle cramps, nausea, dry mucous membranes, and clammy skin. Treatment consists of administering IV fluids with sodium. Medications such as tolvaptan (Samsca) may be administered to increase sodium. Monitor sodium levels.

Hypernatremia

Here, sodium levels are above 145 mEq/L. Hypernatremia is caused by dehydration and an increase in salt intake. Symptoms include edema, weight gain, thirst, weakness, and fatigue. Treatment consists of monitoring sodium intake, administering diuretics to remove sodium, and monitoring daily weights.

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FURTHER READING/STUDY:

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