INTRODUCTION TO MEDICAL-SURGICAL NURSINGINTRODUCTION TO MEDICAL-SURGICAL NURSING

Homeostasis--Body is in a state of equilibrium

•Disease is an impairment of the normal physical &/or mental function

--cold = goosebumps

--fever = diaphoresis

--shock = increased pulse rate

-- maintenance of a stable internalenvironment

•Body used many adaptive measures tomaintain itself

--Many of the signs & symptoms of disease is theresult of this adaptive process

It is our ability to adjust to environmental, physiological, & psychological changes that determines our ability to maintain health

STRESSTRESSS

-- Involves two components:

•Stressor•Stress Response

-- Even the behavior we see are often DefenseMechanism for the reduction of emotionalstress

-- is the response of the body to demandsplaced on it

COMMON STRESSORSCOMMON STRESSORSType of Stressor Examples Manifestations of Stress

Physiological or Biological

•Trauma

•Illness

•Maturation

•Sleep disturbances

•Hunger

•Discomfort

•Pain

Cardiovascular/ respiratory effects--Increased pulse --Increased BP --Rapid, shallowresp.Neurologic effects

--Dilated pupils--Dizziness

--HeadachesG.I. effects--Nausea--Altered appetite--Diarrhea/constipationEndocrine effects--Increased levels

glucose & cortisol

Type of Stressor Examples Manifestations of Stress

Psychological

Cognitive

•Fear

•Worry

•Anger

•Happiness

--Irritability

--Increased sensitivity(feelings are easily hurt)

--Sadness, depression

--Feeling "on edge"

•Thoughts

•Perceptions

•Interpretation of events

•Personal

of eventssignificance

--Impaired memory

--Confusion

--Impaired judgement

--Poor decision making

--Delayed response time

--Altered perceptions

--Inability to concentrate

Type of Stressor Examples Manifestations of Stress

Sociocultural &/or Spiritual

•Job loss orpromotion

•Work situations

•Changes ininterpersonalrelationships

•Interpersonalconflict

--Alienation

--Social isolation

--Feelings ofemptiness

---Some Behavioral Manifestations of Stress include:

•Pacing

•Sweating palms

•Rapid speech

•Insomnia

•Withdrawal

•Exaggerated startle reflex

Stress Response

Adaptation --ongoing process by which anindividual adjust to stress in order to achieve homeostasis

•General response: Shock

•Local: Single organ/systemHow successful a person is in adapting or coping with stress can be influenced by:

•Heredity

•Culture

•Nutrition

•Emotions

•Fatigue

•Age

•Sex

3 Stages of Stress3 Stages of Stress

When stressors are threatening or perceived to be threatening, the body activates physiological changes that ready it for FIGHT OR FLIGHT.

The fight-or-flight response occurs. Long-term coping with stressors depletes adaptive energy, resulting in exhaustion.

When the body has used up its adaptive energy & can no longer cope with stressors, it breaks down in disease, collapse, or death

Stage One: ALARM

Stage Two: RESISTANCE

Stage Three: EXHAUSTION

Supportive CareSupportive Care

•Methods for treatment of stress involves the entire health team

•The nurse is the key personregardless of what therapy used.

•If stressors cause disease, then the nursing role is to provide:

1. Health Education

2. Proper Explanations

3. Comfort Measures

-- teaching stress management

-- eliminating conditionsthat promote stress

-- promoting health behaviorsto avoid stress

•Stress can be reduced through "supportive care"

Nurses work towards supporting the normal adaptive processes used by patients to establish a state of equilibrium

•recognizing emotional needs

•controlling the external environment

As Florence Nightingale once said, "Put the patient in the best condition for nature to act upon him" Notes on Nursing

Nurses recognize that applying stressors are also an important part of the adaptive process:

How?

•food, fluids, medications, exercise, etc

REST & SLEEP

--Characteristics

•Relaxation

•Rest

•Sleep

-- body is less rigid & tense

-- individual seemingly unconscious

-- body & mind in decreasedstate of activity

SLEEP CYCLESLEEP CYCLE

The Sleep Cycle

REMSleep

NREMStage 2

NREMStage 3

NREMStage 4

NREMStage 3

NREMStage 2

NREMStage 1

Adequate high quality sleep is essential forhealth & for physiological & psychological healing to occur

It is believed that during "REM" sleep, adjustment are made that are necessary for learning & memory

Need 20 hoursof sleep Need 5 - 6 hours

Biologic Cycles

-- Biorhythms are physical / mental cycles that reoccur in predictable patterns

-- can be over a long time or in a 24 hour cycle

(Circadian cycle)

-- When our biorhythms are disturbed, we don't feel well.

-- Examples:

•changes in work schedule

•pain•exposure to constant artificial light & noise

•rapidly changing from one time zoneto another

How would knowing about biological rhythms be helpful?

Factors that Influence Sleep

•Age

•Motivation

•Activity

•Drugs

•Environment

•Emotions

•Food/Fluids

•Illness

Sleep loss can result in physical / emotional change•Decreased energy & enthusiasm

•Visual problems

•May become irritable, depressed, indifferent

•Increased sensitivity to pain

•Poor judgement

•Prolonged sleep deprivation can causehallucinations & delusions

--Symptoms frequently seen in patient whorequire frequent vital signs & treatments

COMMON SLEEP PROBLEMS

•InsomniaInsomnia

1. Symptoms

•difficulty falling asleep

•awakening in the night

•early waking

-- Most incidences of insomnia resolvethemselves

-- if last longer than 3 weeks, may becomechronic

2. Treatment

•Lie down only when sleepy

--but not just before bed

•After 20 minutes, if not asleep

--get up, keep busy & occupied

until ready to try again

•Avoid using bed to read orwatch TV

•Daily exercise to increase tiredness

1. More common in children

2. Safety is a factor

3. Some drugs can cause this problem-- some antidepressants, tranquilizers,

or antihistamines

•Somnambulism (Sleepwalking)

1. Due to narrowing of the airpassageways

•Snoring

2. Can be caused by position orsinus problems

•Sleep Apnea (Hypopnea)

1. May experience 30 or more episodes

2. More common in men; in the obese;& increases with age

3. Can be due to obstruction of airways;inhibited ventilatory drive, or both

5. Symptoms:

--hypertension

--daytime fatigue

--morning headache

--personality changes

--intellectual impairment

4. Increased CO2 & decreased O2 causesperson to start breathing

6. Treatment

Nasal CPAP

--Continuous positive airwaypressure (CPAP)

--lose weight

(only 50% successful)

--Uvulopalatopharyngoplastyto remove excess tissuefrom soft palate, uvula, & pharynx

•Narcolepsy

•Sleep talking

--Only disturbs the person sharingthe room

1. Neurological disorder

2. 125,000 in U.S have disorder

--Can occur in families

3. Safety is an issue

4. Treat with drugs that cause wakefulnesssuch as Dexedrine or Ritalin

What do we mean by comfort?Dictionary Definitions: Comfort (Webster)

•1. To soothe in distress or sorrow.

•2. Relief from distress (absence of previous discomfort) (negative sense)

•3. A person or thing that comforts

•4. A state of ease and quiet enjoyment, free from worry (neutral sense)•5. Anything that makes life easy •6. Suggests the lessening of misery or grief by cheering, calming, or inspiring with hope (positive sense)• verb, noun, adjective, adverb

Relief

I need help because I’m lonely.

Ease

I feel totally peaceful.

Transcendence

I did it! (with the help of my coach…)

What do we, as nurses, do to promote physical comfort?

positioning Pain & sleep medsQuiet room

Comfortable lightingLimit visitors

But physical comfort and positioning isn’t the only important type of comfort

There are three more comfort themes that need to be addressed:

1. Comfort theme of self-esteem (psychospiritual)

2. Comfort theme of approach and attitudes of staff (sociocultural)

3. Comfort theme of hospital life (environment).

Technical definition of Comfort

• The state of being strengthened when needs for relief, ease, and transcendence are met in four contexts of experience: physical, psychospiritual, sociocultural, and environmental

• Nice fit with nursing practice!

Comfort Theory (3 parts)

• Comforting interventions enhance patients’ comfort.

• Enhanced patient comfort is positively related to engagement in Health Seeking Behaviors (HSBs) – Comfort is strengthening

• When patients (and families) engage in HSBs, institutions have better outcomes– Patient satisfaction, nurse retention, costs down

•Relationship of comfort (holistic outcome) to health seeking behaviors (HSBs)

– External HSBs: e.g. functional status, rehab progress

– Internal HSBs: e.g. healing, t-cell counts, etc.

– Peaceful death: perfect for hospice and palliative care

Sensory Stimulus

•Stimulus is any change in the environmentthat is sufficient to cause a response

•Can be external and/or internal

•Sensory Overload versus SensoryDeprivation

--both can cause:

1. withdrawal

2. depression

4. confusion

3. impaired problem solving

5. irritability

•Solitude versus Loneliness

•Unpleasant sensation caused by apotentially harmful stimulus

•Nociceptors--nerves that receive & transmit

painful stimuli

•Pain is a personal, subjective feeling

•All pain is real

Components of Pain

•Perception

1. Pain Threshold

2. Pain Tolerance

•Response

Characteristics of Pain•Elderly may have atypical response

•Culture may affect response

•Past experience with pain

•Not always in proportion to tissue damage

•Person must have some degree ofconsciousness

•Pain is very demanding

•The body does not adapt to pain--easily perceived even during sleep

•Anxiety & fear can intensify thepain

Assessment of Pain•Onset

•Location

•Duration

•Quality

•Intensity

--Do this first beforeany intervention

(What personal experiences with pain do you think will most affect your assessment & interventions for pain?)

MEMORY JOGGER FOR PAIN

P Provocative or palliative What provokes or worsens your pain? What relieves or causes the pain to subside?Quality or quantity What does the pain fell like? Is it aching, intense,

knifelike, burning or cramping?

Are you having pain right now? If so, is it more or less severe than usual?

To what degree does the pain affect your normal activities?

Do you have other symptoms along with pain, such as nausea or vomiting?

Q

R Region and radiation Where is your pain? Does the pain radiate to other parts of your body?

Severity How severe is your pain? How would you rat it on

a 0 to 10 scale, with 0 being no pain and 10 being the worst pain imaginable?

How would you describe the intensity of your pain at its best? At its worst? Right now?

S

T Timing When did you pain begin? At what time of day is your pain best? What time is it

worst? Is the onset sudden or gradual? Is the pain constant or intermittent?

Pain Scale

O 1 2 3 4 51) Explain to the child that each face is for a person who feels happy because he or she has no pain (hurt, or whatever word the child uses) or feels sad because he or she has some or a lot of pain.

2) Point to the appropriate face and state, “This face is ….?” 0 – “Very happy because he doesn’t hurt at all.” 1 – “hurts just a little bit.” 2 – “hurts a little more.” 3 – “hurts even more.” 4 – “hurts a whole lot.” 5 – “hurts as much as you can imagine, although you don’t have to be crying to feel this bad.”

3) Ask the child to choose the face that best describes how he or she feels. Be specific about which pain (e.g., “shot” or incision) and what time (e.g., now? earlier before lunch?).

ACUTE PAIN VERSUS CHRONIC PAINACUTE PAIN VERSUS CHRONIC PAINACUTEACUTE CHRONICCHRONIC

Time span Less than 6 months More than 6 months

Location Localized, associated with aspecific injury

Difficult to pinpoint

Characteristics Often described as sharp, diminishes as healing occurs

Often described as dull, diffuse, & aching

Physiologic signs •Elevated heart rate•Elevated BP•Elevated respirations•May be diaphoretic•Dilated pupils

•Normal vital signs•Normal pupils•No diaphoresis•May have loss ofweight

Behavioral signs

•Crying & Moaning•Rubbing site•Guarding•Frowning•Grimacing•Complaints of pain

•Physical immobility•Hopelessness•Listlessness•Loss of libido•Exhaustion & fatigue•Only complains of

pain when asked

Why do nurses tend to underestimate the characteristics of chronic pain?

Intermittent Pain

•Comes & goes•May be acute or chronic

Intractable Pain

•Constant pain

•Usually associated with conditionsconsidered incurable

Referred Pain

•Pain felt in another part of the bodyrather than in the area diseased or injured

Areas of Referred Pain

Liver

Appendix

Ureter

LiverHeartStomach

GallbladderSmall intestines

OvaryKidneyColonBladder

Nursing Interventions:

•Establish a trusting relationship

•Teach patients about their pain

•Document effectiveness

•Focus on patient's responserather than on the size of the dose

A fellow nurse tells you that she only gives half the dose of narcotics to her terminal cancer patient, because of the danger of respiratory depression. What should you do?

•Give pain medication as ordered

Box with batteries

Lead wiresElectrodes

Other treatments for pain control:

•Transcutaneous Electrical Nerve Stimulation(TENS)

--Uses Gate theory

--Stimulates releaseof Endorphins

•if impulses reaches large nerve fibersthey close the gate to small fibers, thus relieving pain

•pain is carried bysmall nerve fibers•non-pain impulsesare carried by large fibers

--may need to destroy nerves

•Surgery

--possible to achieveanesthesia or modify pain

•Hypnosis

•Biofeedback

--teaches patientsto recognize stress-related responses

--give patient a measure of control

Acupuncture/acupressure

•Hot/Cold; imagery/distraction/ massage

•Comfort Measures

1. Quiet room, dim lights, soft music

2. Distraction

3. Soothing bath; back rub

4. Humor

5. Make sure other things aren'tcontributing to the discomfort:(full bladder, thirst, hunger; wrinkled bed)

6. Plan activities so patient is not disturbed frequently

REHABILITATIONREHABILITATION

•Allows client to achieveoptimum level of functioning

•Begins with initial contact

•Should be the underlying themeof nursing care, regardless of setting

Terms:

•Impairment --disturbance in structure orfunction

•Disability --degree of observable andmeasurable impairment

•Handicap --how this disability limits normallevel of functioning

Example:

Jack injured his left leg,

which caused an impairment in his ability to flex his knee 50%.

Since he was a school bus driver, this handicap made him no longer able to operate the bus safely.

Case Study

Mr. Thompson, age 72, suffered a left-sided brain hemorrhage 3 weeks earlier. Because of this, he was unable to speak or use his right arm or leg. He was also incontinent of urine and exhibited some right-sided facial paralysis. After 5 days in the hospital, it was determined that Mr. Thompson’s condition had stabilized, and he was transferred to a rehabilitation facility to continue the rehabilitation process. At this time, his speech had returned, but was slurred and halting.

He had minimal movement in his right arm and leg but was still unable to walk or feed himself. The incontinence of urine persisted, and he had several reddened areas on his right hip and coccyx. Before his injury Mr. Thompson had been living with only his wife of 50 years, who also was in poor health. They had no family living in the state, and she was quite concerned about how she would care for him once he was sent home.

To comprehend all that is involved in helping Mr. Thompson’s return to full functioning (if that is possible), first you need to imagine a typical day in the Thompson household and to identify all the ADL and IADL competencies required to get through the day. Next, think about all the people and services that may be necessary to prevent further injury and to increase functioning.

The Rehabilitation Team

1. Patient

2. Wife

3. Personal physician

4. Rehabilitation physician

5. Rehabilitation nurse

6. Physical therapist

7. Occupational therapist

8. Speech therapist

9. Social worker

10. Clinical nurse specialist

11. Psychologist

12. Recreational therapist

13. Vocational counselor

PATIENT & FAMILY

NUTRITIONIST NURSE

PSYCHOLOGISTPHYSICALTHERAPIST

OCCUPATIONAL THERAPIST

SOCIAL WORKER

PHYSICIAN RECREATIONAL THERAPIST

SPEECH THERAPIST

Rehab Team

Nursing Interventions•Assess the patient's scope of capabilities

--Physical & mental abilities

--Economic status

--Knowledge level

--Patient & family goals

--Experience/Skills

--Home environment

--Motivation

--Community resources

•Prevent deformities and complications

1. Supporting daily self-care

3. Overcoming elimination problems

6. Providing information

2. Assisting with ambulation& mobility

4. Meeting nutritional needs

5. Positive attitude aboutdisabilities/self

Community Assistance

•1954, Vocation Rehab Actprovided for training for employment

•Increased after WWII

•More than 7,000 rehabfacilities in U.S.

•1978, facilities using federal fundsmust make those facilities accessibleto the handicapped

•Based on idea that people have a profoundeffect on one another; both constructive& destructive

Support Groups

•Allows clients to discuss problems in anon-threatening environment

•Can help each other develop soundproblem-solving techniques

CHRONIC ILLNESSCHRONIC ILLNESS

•Not time limited

•Generally accompanies a personfor the remainder of his/her life

•Greater incidence of chronic illness

--estimated that number ofpersons with chronic illness will triple by the year 2040

--worldwide problem

•Development of a chronic illnessis influenced by:

--Heredity

--Lifestyle

--Age

•Stages of Chronic Illness:

1. Development of symptoms

2. Period of accepted illness

3. Convalescence (dealing with disabilities)

***This is the difference between an acuteillness and a chronic illness

CHRONIC CARE CHRONIC CARE GOALSGOALS•Acute care mentality will not work here

•Success is measured differently•May need to be reoriented to a newset of goals

1. Increase self-care capacity

2. Decrease deterioration & decline

3. Promote the highest possiblequality of life

4. Support the dying client

ROLE OF THE LPNROLE OF THE LPN

•All employment areas will dealwith clients with chronic illness

•Many clients will have multi-system involvement

•Need good assessment skills

•Educate yourself & clientsin ways to prevent & decrease complications