NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: FLUID AND ELECTROLYTE IMBALANCES

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

III. COMMON ELECTROLYTE IMBALANCES:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Electrolytes are taken into the body in food s and fluids; normally lost through sweat and urine. May also be lost through hemorrhage, vomiting, and diarrhea. Electrolytes have major influences on: body water regulation and osmolality, acid-base regulation, enzyme reactions, and neuromuscular activity. Clinically important electrolytes are:

A. Sodium (Na+): normal 135 to 145 mEq/L. Most prevalent cation in extracellular fluid. Controls osmotic pressure; essential for neuromuscular functioning and intracellular chemical reactions. Aids in maintenance of acid-base balance. Necessary for glucose to be transported into cells.

  • Hyponatremia—sodium deficit, resulting from either a sodium loss or water excess. Serum sodium level below 135 mEq/L; symptoms usually do not occur until below 120 mEq/L unless rapid drop.
  •  Hypernatremia—excess sodium in the blood, resulting from either high sodium intake, water loss, or low water intake. Serum sodium level above 145 mEq/L.

B. Potassium (K+): normal 3.5 to 5.0 mEq/L. Direct effect on excit ability of nerves and muscles. Contributes to intracellular osmotic pressure and influences acid-base balance. Major cation of the cell. Required for storage of nitrogen a s muscle protein.

  • Hypokalemia—potassium deficit related to dehydration, starvation, vomiting, diarrhea, diuretics. Serum potassium level below 3.5 mEq/L; symptoms may not occur until below 2.5 mEq/L.
  • Hyperkalemia —potassium excess related to severe tissue damage, renal disease, excess administrationof oral or IV potassium. Serum potassium level above 5 mEq/L; symptoms usually occur when above 6.5 mEq/L.

C. Calcium (Ca++): normal 4.5 to 5.5 mEq/L. Essential to muscle metabolism, cardiac function, and bone health. Controlled by parathyroid hormone; reciprocal relationship between calcium and phosphorus.

  • Hypocalcemia—loss of calcium related to inadequate intake, vitamin D deficiency, hypoparathyroidism, damage to the parathyroid gland, decreased absorption in the GI tract, excess loss through kidneys. Serum calcium level below 4.5 mEq/L.
  • Hypercalcemia—calcium excess related to hyperparathyroidism, immobility, bone tumors, renal failure, excess intake of Ca++ or vitamin D. Serum calcium level above 5.5 mEq/L.

D. Magnesium (Mg++): normal 1.5 to 2.5 mEq/L. Essential to cellular metabolism of carbohydrates and proteins.

  • Hypomagnesemia—magnesium deficit related to impaired absorption from GI tract, excessive loss through kidneys, and prolonged periods of poor nutritional intake. Hypomagnesemia leads to neuromuscular irritability. Serum magnesium level below 1.5 mEq/L.
  • Hypermagnesemia—magnesium excess related to renal insufficiency, overdose during replacement therapy, severe dehydration, repeated enemas with Mg++ sulfate (epsom salts). Serum magnesium level above 2.5 mEq/L.

E. Provides assessment, analysis/nursing diagnosis, nursing care plan/implementation, and evaluation/outcome criteria of the various electrolyte imbalances.

IV. ACID-BASE BALANCE: Concentration of hydrogenions in extracellular fluid is determined by the ratio of bicarbonate to carbonic acid. The normal ratio is 20:1. Even when arterial blood gases are abnormal, if the ratio remains at 20:1, no imbalance will occur. Blood Gas Variations with Acid-Base Imbalances shows blood gas variations with acid-base imbalances.

A. Causes of blood gas abnormalities: Blood Gas Abnormalities:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Types of acid-base imbalance:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  •  Acidosis: hydrogen ion concentration increases and pH decreases.
  •  Alkalosis: hydrogen ion concentration decreases and pH increases.
  •  Metabolic imbalances: bicarbonate is the problem. In primary conditions, the level of bicarbonate is directly proportional to pH.
    a. Metabolic acidosis: excessive acid is produced or added to the body, bicarbonate is lost, oracid is retained due to poorly functioning kidneys. Deficit of bicarbonate.
    b. Metabolic alkalosis: excessive acid is lost or bicarbonate or alkali is retained. Excess of bicarbonate.
    c. As compensatory mechanism, PCO2 will be low in metabolic acidosis, as the body attempts to eliminate excess carbonic acid and elevate pH. PCO2 will become elevated in metabolic alkalosis.
  • Respiratory imbalances: carbonic acid is the problem. In primary conditions, PCO2 is inversely proportional to the pH.
    a. Respiratory acidosis: pulmonary ventilation decreases, causing an elevation in the level of carbon dioxide or carbonic acid. Excess of PCO2.
    b. Respiratory alkalosis: pulmonary ventilation increases, causing a decrease in the level of carbon dioxide or carbonic acid. Deficit of PCO2.
    c. As a compensatory mechanism, the level of bicarbonate will increase in respiratory acidosis and decrease in respiratory alkalosis.

C.Assessment:Acid BaseImbalances.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Impaired gas exchange related to hyperventilation.
  • Ineffective breathing pattern related to decreased thoracic movements.
  • Ineffective airway clearance related to retained secretions.
  • Risk for injury related to poorly functioning kidneys.
  • Altered renal tissue perfusion related to dehydration.
  • Altered urinary elimination related to renal failure.
  • Fluid volume excess related to altered kidney function.
  • Fluid volume deficit related to diarrhea or dehydration.
  • Knowledge deficit (learning need) related to self-administration of antacid medications.

E. Nursing care plan/implementation: Acid-Base Imbalances.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client
F. Evaluation/outcome criteria: Acid-Base Imbalances—cont’d.Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

 

Physiological Integrity: Nursing Care of the Adult Client: THE PERIOPERATIVE EXPERIENCE

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. PREOPERATIVE PREPARATION

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Understanding of proposed surgery—site, type, extent of hospitalization.
    b. Previous experiences with hospitalization.
    c. Age-related factors.
    d. Allergies—iodine, latex, adhesive tape, cleansing solutions, medications.
    e. Medication/substance use—prescribed, OTC, smoking, alcohol, recreational drugs.
    f. Cultural and religious background. g. Concerns or feelings about surgery:
    (1) Exaggerated ideas of surgical risk (e.g., fear of colostomy when none is being considered).

(2) Nature of anesthesia (e.g., fears of going to sleep and not waking up, saying or revealing things of a personal nature)

h. Identification of significant others as a source of client support or care responsibilities postdischarge.

  • Objective data:
    a. Speech patterns indicating anxiety— repetition, changing topics, avoiding talking about feelings.
    b. Interactions with others—withdrawn or involved.
    c. Physical signs of anxiety (i.e., increased pulse, respirations; clammy palms, restlessness).
    d. Baseline physiological status: vital signs; breath sounds; peripheral circulation; weight; hydration status (hematocrit, skin turgor, urine output); degree of mobility; muscle strength.

B. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  •  Anxiety related to proposed surgery.
  •  Knowledge deficit (learning need) related to incomplete teaching or lack of understanding.
  •  Fear related to threat of death or disfigurement.
  •  Risk for injury related to surgical complications.
  •  Ineffective individual coping related to anticipatory stress.

C. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: reduce preoperative and intraoperative anxiety and prevent postoperative complications.
    a. Preoperative teaching:
    (1) Provide information about hospital nursing routines and preoperative procedures to reduce fear of unknown.
    (2) Explain purpose of diagnostic procedures to enhance ability to cooperate and tolerate procedure.
    (3) Inform about what will occur and what will be expected in the postoperative period:
    (a) Will return to room, postanesthesia care unit, or intensive care unit (ICU).
    (b) Special equipment—monitors, tubes, suction equipment.
    (c) Pain control methods.
    b. Management of latex allergy if present. Three forms: immediate reaction (most serious, life threatening)—flushing, diaphoresis, pruritus, nausea, vomiting, cramping, hypotension, dyspnea; delayed response (most common, discomfort)—localized symptoms 18 to 24 hours after contact; and contact dermatitis. Exposure to latex through skin, mucous membranes, inhalation, internal tissue, and intravascular; sources include: gloves, anesthesia masks, tourniquets, ECG electrodes, adhesive tape, warming blankets, elastic bandages, tubes/catheters, irrigation syringes. Nursing goal: provide latex-free environment.
  • Goal: instruct in exercises to reduce complications.
    a. Diaphragmatic breathing—refers to flattening of diaphragm during inspiration, which results in enlargement of upper abdomen; during expiration the abdominal muscles are contracted, along with the diaphragm.
    (1) The client should be in a flat, semi- Fowler’s, or side position, with knees flexed and hands on the midabdomen.
    (2) Have the client take a deep breath through nose and mouth, letting the abdomen rise. Hold breath 3 to 5 seconds.
    (3) Have client exhale through nose and mouth, squeezing out all air by contracting the abdominal muscles.
    (4) Repeat 10 to 15 times, with a short rest after each 5 to prevent hyperventilation.
    (5) Inform client that this exercise will be repeated 5 to 10 times every hour postoperatively.

b. Coughing—helps clear chest of secretions and, although uncomfortable, will not harm incision site.
(1) Have client lean forward slightly from a sitting position, and place client’s hands over incisional site; this acts as a splint during coughing.
(2) Have client inhale and exhale slowly several times.
(3) Have client inhale deeply, hold breath 3 seconds, and cough sharply three times while exhaling—client’s mouth should be slightly open.
(4)Tell client to inhale again and to cough deeply once or twice. If unable to cough deeply, client should “huff” cough to stimulate cough.

c. Turning and leg exercises—help prevent circulatory stasis, which may lead to thrombus formation, and postoperative flatus or “gas pains,” as well as respiratory problems.
(1)Tell client to turn on one side with uppermost leg flexed; use side rails to facilitate the movement.
(2) In a supine position, have client do five repetitions every hour of: ankle pumps, quadriceps-setting exercises, gluteal tightenings, and straight-leg raises.
(3) Apply intermittent pulsatile compression device or sequential compression device to promote venous return.

  • Goal: reduce the number of bacteria on the skin to eliminate incision contamination. Skin preparation:
    a. Prepare area of skin wider and longer than proposed incision in case a larger incision is necessary.
    b. Gently scrub with an antimicrobial agent.
    (1) Note possibility of allergy to iodine.
    (2) Hexachlorophene should be left on the skin for 5 to 10 minutes.
    (3) If benzalkonium Cl (Zephiran) solution is ordered, do not soap skin before use; soap reduces effectiveness of benzalkonium by causing it to precipitate.

c. Hair should remain unless it interferes with surgical procedure.
(1) Note any nicks, cuts, or irritations, potential infection sites.
(2) Depilatory creams or clipping of hair is preferred to shaving with a razor; nick may result in cancellation of surgery.
(3) Skin prep may be done in surgery.

  • Goal: reduce the risk of vomiting and aspiration during anesthesia; prevent contamination of abdominal operative sites by fecal material. Gastrointestinal tract preparation:
    a. No food or fluid at least 6 to 8 hours before surgery.
    b. Remove food and water from bedside.
    c. Place NPO signs on bed or door.
    d. Inform kitchen and oncoming nursing staff that client is NPO for surgery.
    e. Give IV infusions up to time of surgery if dehydrated or malnourished.
    f. Enemas: two or three may be given the evening before surgery with intestinal, colon, or pelvic surgeries; 3 days of cleansing with large intestine procedures.
    g. Possible antibiotic therapy to reduce colonic flora with large bowel surgery.
    h. Gastric or intestinal intubation may be inserted the evening before major abdominal surgery.

(1) Types of tubes:
(a) Levin: single lumen; sufficient to remove fluids and gas from stomach; suction may damage mucosa.
(b) Salem sump: large lumen; prevents tissue-wall adherence.
(c) Miller-Abbott: long single or double lumen; required to remove the contents of jejunum or ileum.
(2) Pressures: low setting with Levin and intestinal tubes; high setting with Salem sump; excessive pressures will result in injury to mucosal lining of intestine or stomach.

  • Goal: promote rest and facilitate reduction of apprehension.
    a. Medications as ordered: on evening before surgery may give barbiturate—pentobarbital (Nembutal), secobarbital (Seconal).
    b. Quiet environment: eliminate noises, distractions.
    c. Position: reduce muscle tension.
    d. Back rub.
  • Goal: protect from injury; ensure final preparation for surgery. Day of surgery:
    a. Operative permit signed and on chart; physician responsible for obtaining informed consent. Possible blood products consent.
    b. Shower or bathe.
    (1) Dress: hospital pajamas.
    (2) Remove: hairpins (cover hair); nail polish, to facilitate observation of peripheral circulation; jewelry (or tape wedding bands securely); pierced earrings; contact lenses; dentures (store and give mouth care); give valuable personal items to family; chart disposition of items.
    c. Proper identification—check band for secureness and legibility; surgical site (limb) may be marked to prevent error.
    d. Vital signs—baseline data.
    e. Void, to prevent distention and possible injury to bladder.

f. Give preoperative medication to ensure smooth induction and maintenance of anesthesia—antianxiety (e.g., midazolam, diazepam, lorazepam); narcotics (e.g., meperidine, morphine, fentanyl); anticholinergics (e.g., atropine, glycopyrrolate).
(1) Administered 45 to 75 minutes before anesthetic induction.
(2) Side rails up (client will begin to feel drowsy and light-headed).
(3) Expect complaint of dry mouth if anticholinergics given.
(4) Observe for side effects—narcotics may cause nausea and vomiting, hypotension, arrhythmias, and/or respiratory depression.
(5) Quiet environment until transported to operating room (OR).
(6) Anticipate antibiotics to start “on call” to OR.

g. Note completeness of chart:
(1) Surgical checklist completed.
(2) Vital signs recorded.
(3) Routine laboratory reports present.
(4) Preoperative medications given.
(5) Significant client observations.
h. Assist client’s family in finding proper waiting room.
(1) Inform family members that the surgeon will contact them after the procedure is over.
(2) Explain length of time client is expected to be in recovery room.
(3) Prepare family for any special equipment or devices that may be needed to care for client postoperatively (e.g., oxygen, monitoring equipment, ventilator, blood transfusions).

II. INTRAOPERATIVE PREPARATION—anesthesia: blocks transmission of nerve impulses, suppresses reflexes, promotes muscle relaxation, and in some
instances achieves reversible unconsciousness.

A. Intravenous conscious sedation—produces sedation and amnesia in ambulatory procedures, short surgical or diagnostic procedures. Allays fear and anxiety, elevates pain threshold,maintains consciousness and protective reflexes, and returns client quickly to normal activities. Commonly used agents are benzodiazepines (midazolam [Versed], diazepam) and narcotics (fentanyl [Sublimaze], meperidine, morphine).

B. Regional anesthesia—purpose is to block pain reception and transmission in a specified area. Commonly used drugs are lidocaine HCl, tetracaine HCl, cocaine HCl, and procaine HCl. Types of regional anesthetics:

  • Topical—applied to mucous membranes or skin; drug anesthetizes the nerves immediately below the area. May be used for bronchoscopic or laryngoscopic examinations. Side effects: rare anaphylaxis.
  • Local infiltration—used for minor procedures; anesthetic drug is injected directly into the area to be incised, manipulated, or sutured. Side effects: rare anaphylaxis.
  • Peripheral nerve block—regional anesthesia is achieved by injecting drug into or around a nerve after it passes from vertebral column; procedure is named for nerve involved, such as brachial plexus block. Requires a high degree of anatomical knowledge. Side effects: may be absorbed into bloodstream. Observe for: signs of excitability, twitching, changes in vital signs, or respiratory difficulties.
  • Field block—a group of nerves is injected with anesthetic as the nerves branch from a major or main nerve trunk. May be used for dental procedures, plastic surgery. Side effects: rare.
  • Epidural anesthesia—anesthetizing drug is injected into the epidural space of vertebral canal; produces a bandlike anesthesia around body. Frequently used in obstetrics. Rare complications. Slower onset than spinal anesthesia; not dependent on client position for level of anesthesia; no postoperative headaches.
  • Spinal anesthesia—anesthetizing drug is injected into the subarachnoid space and mixes with spinal fluid; drug acts on the nerves as they emerge from the spinal cord, thereby inhibiting conduction in the autonomic, sensory, and motor systems.

a. Advantages: rapid onset; produces excellent muscle relaxation.
b. Utilization: surgery on lower limbs, inguinal region, perineum, and lower abdomen.
c. Disadvantages:
(1) Loss of sensation below point of injection for 2 to 8 hours—watch for signs of bladder distention; prevent injuries by maintaining alignment, keeping bedclothes straightened.

(2) Client awake during surgical procedure— avoid light or upsetting conversations.
(3) Leakage of spinal fluid from puncture site—keep flat in bed for 24 to 48 hours to prevent headache. Keep well hydrated to aid in spinal fluid replacement.
(4) Depression of vasomotor responses— frequent checks of vital signs.

  • Intravenous regional anesthesia—used in an extremity whose circulation has been interrupted by a tourniquet; the anesthetic is injected into vein, and blockage is presumed to be achieved from extravascular leakage of anesthetic near a major nerve trunk. Precautions as for peripheral nerve block.

C. General anesthesia—a reversible state in which the client loses consciousness due to the inhibition of neuronal impulses in the brain by a variety of chemical agents; may be given intravenously, by inhalation, or rectally.

  • Side effects:
    a. Respiratory depression.
    b. Nausea, vomiting.
    c. Excitement.
    d. Restlessness.
    e. Laryngospasm.
    f. Hypotension.
  • Nursing care plan/implementation—Goal: prevent hazardous drug interactions.
    a. Notify anesthesiologist if client is taking any of the following drugs:
    (1) Antidepressants, such as Prozac—long half-life; monitor renal and liver function.
    (2) Antihypertensives, such as reserpine, hydralazine, and methyldopa—potentiate the hypotensive effects of anesthetic agents.
    (3) Anticoagulants, such as heparin, warfarin (Coumadin)—increase bleeding times, which may result in excessive blood loss or hemorrhage.
    (4) Aspirin and NSAIDs—decrease platelet aggregation and may result in increased bleeding.
    (5) Steroids, such as cortisone—antiinflammatory effect may delay wound healing.

b. Stages of inhalation anesthesia and nursing goals:
(1) Stage I—extends from beginning of induction to loss of consciousness. Nursing goal: reduce external stimuli, because all movement and noises are exaggerated for the client and can be highly distressing.
(2) Stage II—extends from loss of consciousness to relaxation; stage of delirium and excitement. Nursing goal: prevent injury by assisting anesthesiologist to restrain client if necessary; maintain a quiet, nonstimulating environment.

(3) Stage III—extends from loss of lid reflex to cessation of voluntary respirations. Nursing goal: reduce risk of untoward effects by preparing the operative site, assisting with procedures, and observing for signs of complications.
(4) Stage IV—indicates overdose and consists of respiratory arrest and vasomotor collapse due to medullary paralysis. Nursing goal: promote restoration of ventilation and vasomotor tone by assisting with cardiac arrest procedures and by administering cardiac stimulants or narcotic antagonists as ordered.

D. Intravenous agents—rapid and pleasant induction of anesthesia. Three categories: barbiturates (thiopental), narcotics, and neuromuscular blocking agents (succinylcholine, curare, pancuronium). Ketamine also used—may produce emergence delirium. IV drugs require liver metabolism and renal excretion.

E. Hypothermia—a specialized procedure in which the client’s body temperature is lowered to 28° to 30°C (82° to 86°F).

  • Reduces tissue metabolism and oxygen requirements.
  • Used in heart surgery, brain surgery, and surgery on major blood vessels.
  • Nursing care plan/implementation:
    a. Goal: prevent complications.
    (1) Monitor vital signs for shock.
    (2) Note level of consciousness.
    (3) Record intake and output accurately.
    (4) Maintain good body alignment; reposition to prevent edema, pressure, or discoloration of skin.
    (5) Maintain patent IV.
    b. Goal: promote comfort.
    (1) Apply blankets to rewarm and prevent shivering.
    (2) Mouth care.

c. Goal: observe for indications of malignant hyperthermia—common during induction; may occur 24 to 72 hours postoperatively. Genetic defect of muscle metabolism; early sign is unexplained ventricular dysrhythmia, tachypnea, cyanosis, skin mottling; elevated temperature is not reliable indicator.
(1) Administer 100% O2.
(2) Cool with ice packs or cooling blankets.
(3) Give dantrolene (muscle relaxant) per order.

F. Evaluation/outcome criteria: complete reversal of anesthetic effects (e.g., spontaneous respirations, pupils react to light). No indication of intraoperative complications—cardiac arrest, laryngospasm, aspiration, hypotension, malignant hyperthermia.

III. POSTOPERATIVE EXPERIENCE

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

A. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:
    a. Pain: location, onset, intensity.
    b. Nausea.
  • Objective data:
    a. Operative summary:
    (1) Type of operation performed.
    (2) Pathological findings if known.
    (3) Anesthesia and medications received.
    (4) Problems during surgery that will affect recovery (e.g., arrhythmias, bleeding [estimated blood loss]).
    (5) Fluids received: type, amount.
    (6) Need for drainage or suction apparatus.
    b. Observations:
    (1) Patency of airway.
    (2) Vital signs.
    (3) Skin color and dryness.
    (4) Level of consciousness.
    (5) Status of reflexes.
    (6) Dressings.
    (7)Type and rate of IV infusion and blood transfusion.
    (8)Tubes/drains: urinary, chest, Penrose, Hemovac; note color and amount of drainage.

B. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective breathing pattern related to general anesthesia.
  • Ineffective airway clearance related to absent or weak cough.
  • Risk for aspiration related to vomiting.
  • Pain related to surgical incision.
  • Altered tissue perfusion related to shock.
  • Risk for fluid volume deficit related to blood loss.
  • Risk for injury related to disorientation.
  • Risk for infection related to disruption of skin integrity.
  • Urinary retention related to anesthetic effects.
  • Constipation related to decreased peristalsis.

C. Nursing care plan/implementation—immediate postanesthesia nursing care: refers to time following surgery that is usually spent in the recovery room (1 to 2 hours).

  • Goal: promote a safe, quiet, nonstressful environment.
    a. Side rails up at all times.
    b. Nurse in constant attendance.
  • Goal: promote lung expansion and gas exchange.
  • Goal: Prevent aspiration and atelectasis.
    a. Position: side or back, head of bed (HOB) 30 degrees, head turned to side to prevent obstruction of airway by tongue; allows for drainage from mouth.
    b. Airway: leave the oropharyngeal or nasopharyngeal airway in place until client awakens and begins to eject; gagging and vomiting may occur if not removed before pharyngeal reflex returns.

c. After removal of airway: turn on side in a lateral position; support upper arm with pillow.
d. Suction: remove excessive secretions from mouth and pharynx.
e. Encourage coughing and deep breathing: aids in upward movement of secretions.
f. Give humidified oxygen as necessary: reduces respiratory irritation and keeps bronchotracheal secretions soft and moist.
g. Mechanical ventilation: respirators if needed.

  • Goal: promote and maintain cardiovascular function.
    a. Vital signs, as ordered: usually q5–15 min until stable; continuous pulse oximetry.
    (1) Compare with preoperative vital signs.
    (2) Immediately report: systolic blood pressure that drops 20 mm Hg or more, a pressure below 80 mm Hg, or a pressure that continually drops 5 to 10 mm Hg over several readings; pulse rates under 60 or over 110 beats/min, or irregularities; respirations over 30/min; becoming shallow, quiet, slow; use of neck and diaphragm muscles (symptoms of respiratory depression); stridorous breath sounds.

b. Observe for other alterations in circulatory function—pallor; thready pulse; cold, moist skin; decreased urine output, restlessness.
(1) Immediately report to physician.
(2) Initiate oxygen therapy.
(3) Place client in shock position unless contraindicated—feet elevated, legs straight, head slightly elevated to increase venous return.
c. Intravenous infusions: time, rate, orders for added medications.
d. Monitor blood transfusions if ordered: observe for signs of reaction (chills, elevated temperature, urticaria, laryngeal edema, and wheezing). Postoperative Complications illustrates the nursing care plan/implementation.
e. If reaction occurs, immediately stop transfusion and notify physician. Send STAT urine to laboratory.

  • Goal: promote psychological equilibrium.
    a. Reassure on awakening—orient frequently.
    b. Explain procedures even though client does not appear alert.
    c. Answer client’s questions briefly and accurately.
    d. Maintain quiet, restful environment.
    e. Comfort measures:
    (1) Good body alignment.
    (2) Support dependent extremities to avoid pressure areas and possible nerve damage.
    (3) Check for constriction: dressings, clothing, bedding.
    (4) Check IV sites frequently for patency and signs of infiltration (swelling, blanching, cool to touch).
  • Goal: maintain proper function of tubes and apparatus

D. Nursing care plan/implementationgeneral postoperative nursing care: refers to period of time from admission to the general nursing unit until anticipated recovery and discharge from the hospital (Postoperative Complications for a review of postoperative complications).

  • Goal: promote lung expansion, gaseous exchange, and elimination of bronchotracheal secretions.
    a. Turn, cough, and deep breathe q2h.
    b. Use incentive spirometer as ordered to enable client to observe depth of ventilation.
    c. Administer nebulization as ordered to help mobilize secretions.
    d. Encourage hydration to thin mucous secretions.
    e. Assist in ambulation as soon as allowed.
  • Goal: provide relief of pain.
    a. Assess type, location, intensity, and duration; possible causative factors, such as poor body alignment or restrictive bandages.

b. Observe and evaluate reaction to discomfort. Use scale: 1 to 10 numerical or pictorial.
c. Use comfort measures, such as back rubs and proper ventilation, staying with client and encouraging verbalization.
d. Reduce incidence of pain: change position frequently; support dependent extremities with pillows, sandbags, and footboards; keep bedding dry and straight.
e. Give analgesics or tranquilizers as ordered; assure client that they will help.
f. Observe for desired and untoward effects of medication.

  • Goal: promote adequate nutrition and fluid and electrolyte balance.
    a. Parenteral fluids, as ordered.
    b. Monitor blood pressure, I&O to assess adequate, deficient, or excessive extracellular fluid volume.

c. Diet: liquid when nausea and vomiting stop and bowel sounds are established; progress as ordered.

  • Goal: assist client with elimination.
    a. Encourage voiding within 8 to 10 hours after surgery.
    (1) Allow client to stand or use commode, if not contraindicated.
    (2) Run tap water or soak feet in warm water to promote micturition.
    (3) Catheterization if bladder is distended and conservative treatments have failed.
    b. Maintain accurate I&O records.
    c. Expect bowel function to return in 2 to 3 days.
  • Goal: facilitate wound healing and prevent infection.
    a. Incision care: avoid pressure to enhance venous drainage and prevent edema.
    b. Elevate injured extremities to reduce swelling and promote venous return.
    c. Support or splint incision when coughing.
    d. Check dressings q2h for drainage.
    e. Change dressings on draining wounds prn; aseptic technique; protective ointments to reduce skin irritation may be ordered.
    f. Carefully observe wound suction (e.g., Jackson Pratt), if applied, for kinking or twisting of the tubes.
  • Goal: promote comfort and rest.
    a. Recognize factors that may cause restlessness— fear, anxiety, pain, oxygen lack, wet dressings.
    b. Comfort measures: analgesics or barbiturates; apply oxygen as indicated; change positions; encourage deep breathing; massage back to reduce restlessness.
    c. Allow rest periods between care—group activities.
    d. Give antiemetic for relief of nausea and vomiting, as ordered.
    e. Vigorous oral hygiene (brushing) to prevent “surgical mumps” or parotitis from preoperative atropine or general anesthesia.
  • Goal: encourage early movement and ambulation to prevent complications of immobilization.
    a. Turn or reposition q2h.
    b. Range of motion (ROM): passive and active exercises.
    c. Encourage leg exercises.
    d. Use preventive treatments—antiembolic stockings, graduated compression stockings, or external pneumatic compression sleeves:
    (1) With compression stockings, highest pressure (100%) at ankles, lowest pressure (40%) at midthigh.
    (2) Compression sleeves, three chambers sequentially inflated-deflated to stimulate venous return.

e. Assist with standing or use of commode if allowed.
f. Encourage resumption of personal care as soon as possible.
g. Assist with ambulation in room as soon as allowed. Avoid prolonged chair sitting because it enhances venous pooling and may predispose to thrombophlebitis. Elevate legs when chair sitting.

E. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Incision heals without infection.
  • No complications (e.g., atelectasis, pneumonia, thrombophlebitis).
  • Normal bowel and bladder functions resume.
  • Carries out activities of daily living, self-care.
  • Accepts possible limitations: dietary, activity, body image (e.g., no depression, complies with treatment regimen).

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client

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Physiological Integrity: Nursing Care of the Adult Client: PAIN MANAGEMENT

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

I. PAIN—the “fifth vital sign” in the care of clients; a complex subjective sensation; unpleasant sensory and emotional experience associated with real or potential tissue damage. Pain is considered to be whatever the person experiencing it says it is, existing whenever he or she says it does.

A. Classifications:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  •  Acute pain: lasts typically less than 1 month; characterized by: tachycardia, tachypnea, increased BP, diaphoresis, dilated pupils. Responsive to analgesics.
  •  Chronic pain: persists or is recurring for longer than 3 months; often characterized by: lassitude, sleep disturbance, decreased appetite, weight loss, diminished libido, constipation, depression. Rarely responsive to analgesics.
  •  Somatogenic (organic/physiological):
    a. Nociceptive: somatic or visceral pain—sensations, normal pain transmission, such as aching or pressure (e.g., cancer pain,
    chronic joint and bone pain).
    b. Neuropathic: aberrant processes in peripheral and/or central nervous system; part of a defined neurological problem; sensations such as sharp, burning, shooting pain (e.g., nerve compression, polyneuropathy, central pain of stroke, phantom pain after amputation).
  •  Psychogenic (without organic pathology sufficient to explain pain).

B. Components of pain experience—pain related to:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Stimuli—sources: chemical, ischemic, mechanical trauma, extremes of heat/cold.
  • Perception—viewed with fear by children, can be altered by level of consciousness, interpreted and influenced by previous and current experience, is more severe when alone at night or immobilized.
  • Response—variations in physiological, cultural, and learned responses; anxiety is created; pain seen as justified punishment; pain used as means for attention-getting.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data (Required Pain Assessment on Admission for Clients Who are Hospitalized):
    a. Site—medial, lateral, proximal, distal.
    b. Strength:
    (1) Certain tissues are more sensitive.
    (2) Change in intensity.
    (3) Based on expectations.
    (4) Affected by distraction or concentration, state of consciousness.
    (5) Described as: slight, medium, severe, excruciating.
    c. Quality—aching, burning, crushing, dull, piercing, shifting, throbbing, tingling.
    d. Antecedent factors—physical exertion, eating, extreme temperatures, physical and emotional stressors (e.g., fear).
    e. Previous experience—influences reaction to pain.
    f. Behavioral clues—demanding, worried, irritable, restless, difficult to distract, sleepless.
  • Objective data:
    a. Verbal clues—moaning, groaning, crying.
    b. Nonverbal clues—clenching teeth, grimacing; splinting of body parts, body position, knees drawn up, involuntary reflex movements; tossing/turning, rhythmic rubbing movements; voice pitch and speed; eyes shut.
    c. Physical clues—breathing irregularities, abdominal distention; skin color changes, skin temperature changes; excessive salivation, perspiration.
    d. Time/duration—onset, duration, recurrence, interval, last occurrence.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain, acute or chronic, related to specific client condition.
  •  Activity intolerance related to discomfort.
  •  Sleep pattern disturbance related to pain.
  •  Fatigue related to state of discomfort or emotional stress.
  •  Ineffective individual coping related to chronic pain.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: provide relief of pain.
    a. Assess level of pain; ask client to rate on scale of 0 to 10 (0 = no pain; 10 = worst pain) or smiling/sad faces. Use age-, condition-, and language-appropriate scale (Format for Assessing Pain).
    b. Determine cause and try nursing comfort measures before giving drugs:
    (1) Environmental factors: noise, light, odors, motion.
    (2) Physiological needs: elimination, hunger, thirst, fatigue, circulatory impairment, muscle tension, ventilation, pressure on nerves.
    (3) Emotional: fear of unknown, helplessness, loneliness (especially at night).
    c. Relieve: anger, anxiety, boredom, loneliness.
    d. Report sudden, severe, new pain; pain not relieved by medications or comfort measures; pain associated with casts or traction.
    e. Remove pain stimulus:

(1) Administer pain medication—nonopioids: NSAIDs—ketorolac (Toradol); opioids: first-line analgesics include morphine, hydromorphone, fentanyl, oxycodone, hydrocodone ; adjuvants: local anesthetics, sedatives, muscle relaxants; give at appropriate time intervals; do not withhold due to overestimated danger of addiction.

 (2) Avoid cold (to reduce immediate tissue reaction to trauma).

(3) Apply heat (to relieve ischemia).
(4) Change activity (e.g., restrict activity in cardiac pain).
(5) Change, loosen dressing.
(6) Comfort (e.g., smooth wrinkled sheets, change wet dressing).
(7) Give food (e.g., for ulcer).
(8) Decrease stimulation (e.g., ↓ bright lights, noise, temperature).

f. Reduce pain receptor reaction.
(1) Ointment (use as coating).
(2) Local anesthetics.
(3) Padding (of bony prominences).
g. Assist with medical-surgical interventions to block pain impulse transmission:
(1) Injection of local anesthetic into nerve (e.g., dental).
(2) Cordotomy—sever anterolateral spinal cord nerve tracts.
(3) Electrical stimulation—transcutaneous (skin surface), percutaneous (peripheral nerve).
(4) Peripheral nerve implant—electrode to major sensory nerve.
(5) Dorsal column stimulator—electrode to dorsal column.
h. Minimize barriers to effective pain management:
(1) Achieve “balanced analgesia”; aroundthe-clock administration of NSAIDs or acetaminophen if possible, continuous infusion, patient-controlled analgesia (PCA); combination therapy (opioids, nonopioids, adjuvants).
(2) Accept client and family report of pain.
(3) Discuss fear of addiction with client family (incidence <1% when opioids taken for pain relief).
(4) Discuss fear of respiratory depression with staff; preventable; related to sedation.
i. Document response to pain relief measures.

  • Goal: use nonpharmacological methods to reduce pain.
    a. Distraction, such as TV (cerebral cortical activity blocks impulses from thalamus).
    b. Aromatherapy—assists in relaxation.
    c. Hypnosis—assess appropriateness for use for psychogenic pain and for anesthesia; client needs to be open to suggestion.
    d. Acupuncture—assess emotional readiness and belief in it.
  • Goal: alter interpretation and response to pain.
    a. Administer narcotics—result: no longer sees pain as disturbing.
    b. Administer hypnotics—result: changes perception and decreases reaction.
    c. Help client obtain interpersonal satisfaction from ways other than attention received when in pain.
  • Goal: promote client control of pain and analgesia: patient-controlled analgesia (PCA), an analgesia administration system designed to maintain optimal serum analgesia levels; safely delivers intermittent bolus doses of a narcotic analgesic; preset to maximum hourly dose.
    a. Advantages: decreased client anxiety; improved pulmonary function; fewer side effects.
    b. Limitations: requires an indwelling intravenous line; analgesia targets central pain, may not relieve peripheral discomfort; cost of PCA unit.
  • Goal: health teaching.
    a. Explain causes of pain and how to describe pain.
    b. Explain that it is acceptable to admit existence of pain.
    c. Relaxation exercises.
    d. Biofeedback methods of pain perception and control.
    e. Proper medication administration (PCA, continuous around-the-clock dosing), when necessary, for self-care.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  •  Verbalizes comfort; awareness of pain decreased.
  •  Knows source of pain; how to reduce stimulus and perception.
  •  Uses alternative measures for pain relief.
  •  Able to cope with pain (e.g., remains active, relaxed appearance; verbal and nonverbal clues of pain absent).
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