NURSING 103: CHAPTER 26 NOTES

BOWEL ELIMINATION
ANATOMICAL STRUCTURES OF THE GASTROINTESTINAL TRACT
- GI tract is a smooth muscle tube approximately 30 Feet long, running through the body form the mouth to the anus.
- Its major functions are to digest and absorb the nutrients present in food and to eliminate food waste products as feces.

UPPER GASTROINTESTINAL TRACT

MOUTH
- Mechanical digestion begins in the mouth
- Mastication - chewing.
- Food is torn into small pieces, mashed with saliva, and formed into a bolus that is then swallowed into the esophagus.
- The mouth contains glands that secrete enzymes like ptyalin and salivary amylase, which begin digestion of carbohydrates.

PHARYNX
- Pharynx is the back part of the throat where food and air pass after chewing.
- To prevent choking and aspiration a flap of connective tissue, called the Epiglottis, closes over the trachea when food is swallowed.

ESOPHAGUS
- The esophagus is a tube of smooth muscle that alternately contracts and relaxes in waves of peristalsis to push the bolus toward the stomach.
- The bolus travels the length of the esophagus in about 15 seconds.
- The Gastroesophageal sphincter relaxes to allow the food to pass into the stomach, and protects from acidic stomach contents from flowing back into
the esophagus.

THE STOMACH
- The distensible sac that extends from the esophagus to the small intestine is the stomach.
- It stores food while it churns and mixes it, providing further mechanical breakdown.
- Chemical digestion continues in the stomach, which secretes hydrochloric acid, pepsin, and gastric lipase, an enzyme that begins the digestion lipids.
- The stomach secretes a mucous coating that protects the stomach from being corroded by HCI
- Food remains in the stomach an average of 4 hours
- Food leaves the stomach as a liquid called Chyme

THE SMALL INTESTINE

- The small intestine is a folded, twisted, and coiled tube that connects the stomach and the large intestine.
- Most digestion and absorption of food occur in the small intestine.
- Chyme travels through it slowly, by peristalsis
- Peristalsis halts periodically to allow for absorption.
- Small intestine consists of three segments:
- Duodenum - is th first section of the small intestine. It is a C shaped tube that branches off from the stomach, about 30 to 60 cm long.
- Processes Chyme by mixing it and adding enzymes.
- The bile duct and main pancreatic duct both enter the small intestine at the duodenum level.
- Jejunum - is the coiled midsection of the small intestine. It forms the connection between the duodenum and ileum.
- Its major function is to absorb carbohydrates and proteins.
- Ileum - joins the small and large intestines. It is responsible for the absorption of fats; bile salts; and some vitamins, minerals, and water.
- Key Point: Nutrients are absorbed mainly in the duodenum and Jejunum

- The total length of the small intestine, if stretched out, is approximately 20 feet
- The inner wall of the small intestine is covered by millions of tiny finger like projections called villi
- The villi are covered in tiny projections, called microvilli

THE LARGE INTESTINE

- The large intestine or the colon, is larger in diameter than the small intestine but shorter in length.
- It extends from the ileum of the small intestine to the anus.
- It contains seven segments:
- Cecum - undigested food entering the first portion of the large intestine consists mostly of cellulose and water
- Ileocecal Valve - controls the connection of the ileum to the cecum, preventing backflow of chyme from the colon into the small
intestine.

- Appendix - is a small, finger-like appendage off the cecum. It is believed to have reduced significance over time for the body,
although it does aid in immune function.

- Ascending, Traverse, and Descending Colon

- Sigmoid Colon
- Is the final small segment of bowel that twists medially and downward to connect with the rectum and anus.
 - Functions of the Colon
- The colon secretes mucus, which facilitates smooth passage of stool, and absorbs water, some vitamins, and minerals.
- Approximately 80% of the fluid that enters the colon is reabsorbed along its passage.
- Normal Flora in the colon aid in the digestive process and are responsible for producing vitamin K and several of the B vitamins.
- Peristalsis
- Taenia Coli are the longitudinal muscles that run lengthwise along the colon surface.
- Haustra - pouched segments that gather tension in the muscles in the colon.
- Haustral Churning - moves digestive contents around within each haustra.
- Peristalsis - is a powerful contraction along a lengthy segment of bowel.
- Mass Peristalsis - is a powerful contraction along a lengthy segment of bowel
- Gastrocolic reflex is triggered by food entering the stomach and small intestine.

RECTUM & ANUS

- Rectum - is approximately 15 cm long and is continuous with the anus, is a highly vascular folded tube, the rectum is free of waste products until just
before defecation.

- Anus - is 2.5 cm of the colon, is highly vascular.

- Internal sphincter involuntarily relaxes and opens when stool is present in the rectum.
- External sphincter is under voluntary control.
- Allows stool to be expelled from the body.

HOW DOES THE BOWEL ELIMINATE WASTE

- Feces - is the reabsorption of water from chyme in the large intense resulting in a semisolid mass.
- Feces are a mixture of fiber, undigested food, shed epithelial cells, inorganic material, bacteria, and water.
- Feces are brown because of Bile salts, which aid in digestion of fat, and are excreted in the feces.
- Flatus, or gas, is formed in the digestive process.
- Some is swallowed air that accompanies the intake of food
- Most gas is bacterial fermentation in the colon

THE PROCESS OF DEFECATION

- Defecation - is the process by which the bowel eliminates waste.
1. Stretch receptors are stimulated to start contraction of the sigmoid colon and rectal muscles.
2. The internal anal sphincter relaxes.
3. At the same time, sensory impulses transmitted to the central nervous system produce a conscious urge to defecate.
- We respond to this signal by voluntarily contracting our diaphragmatic and abdominal muscles to increase downward pressure, while at the same time
relaxing the external anal sphincter. These actions allow feces to be propelled through the anus.

- Valsalva Maneuver - Contracting the abdominal muscles while maintaining a closed airway.
- Patients with heart disease, glaucoma, increased intracranial pressure, or new surgical wound should avoid the valsalva maneuver because it
increases pressure within the abdominal cavity.

NORMAL DEFECATION PATTERNS

- Normal Stool is soft, formed semisolid, approximately 75% water and 35% solid when expelled.
- Slow passage through the colon means more water is reabsorbed from the feces resulting in dry hard stool.
- If passage is fast through the colon less water is reabsorbed, and stools are watery.

- Key Point: As long as the person passes stools without excessive urgency with minimal effort and no straining, without blood loss, and without the use
of laxatives, you can regard bowel function normal.

FACTORS AFFECTING BOWEL ELIMINATION

DEVELOPMENTAL STAGE
INFANTS
- Newborns passes meconium through the anus
- Meconium - is green black, tarry, sticky and odorless, Formed by swallowed mucus, hair, and amniotic fluid.
- Stools transition from yellow - green color over the next few days.
- After that, breastfed babies pass golden yellow stools, whereas formula fed babies pass tan stools.
- Initially babies defecate frequently, until normal flora develop in the colon and stools become firmer and less frequent.
CHILDREN
- The ability to control defecation develops at about age 2 to 3 years.
- Toilet training requires neural and muscular control as well as conscious effort.
- The child must be aware of the urge to defecate, be able to maintain closure of the external anal sphincter while getting on the toilet.

ADULTS
- Bowel pattern set in childhood normally continues into late adulthood if the client consumes adequate fiber and fluid and engages in regular physical
exercise.
PERSONAL & SOCIOCULTURAL FACTORS
PRIVACY & TIME
- Patients with fast paced jobs may have difficulty even consciously recognizing the need to defecate, and some habitually ignore need, promoting bowel
dysfunction.
- Parents and caregivers of infants and toddlers may postpone their own toileting needs because of fear of leaving the children alone.
- Some clients are acutely embarrassed by the thought that anyone might realize they are having a bowel movement and will wait until they are entirely
alone before even entering the bathroom.

STRESS
- Stress has a major influence on motility of the GI tract.
- It may cause diarrhea or constipation, and it is a primary risk factor for irritable bowel syndrome.

NUTRITION / HYDRATION / ACTIVITY LEVEL

- A regular Schedule for eating
- People who eat on a regular schedule are likely to develop a regular pattern of defecation.

- Adequate intake of fiber

- Fiber promotes peristalsis and defecation.
- Bulky foods absorb fluids and increase stool mass.
- Most people should have at least five servings of high fiber foods each day.

- Some foods have specific effects in the bowel

- Active Bacteria in yogurt stimulates peristalsis and promotes healing of intestinal infections
- Low fiber foods, slow peristalsis
- Broccoli, Onion, Beans, and similar foods lead to excess gas in many people.
- Spicy foods may also cause gas or frequent Bowel Movements.
- Dietary Supplements
- Calcium supplements may cause constipation
- Magnesium loosens stools.
- Supplemental Vitamin C Softens Stools and in high doses may cause diarrhea in sensitive clients.
- Fluids
- A minimum of six to eight 8 ounce glasses of fluid per day is required to promote healthful bowel function.
- Inadequate fluid intake or excessive fluid loss slows peristalsis and leads to dry, hard stools that are difficult to pass
- Excessive fluid intake may lead to rapid passage through the colon and soft or watery stools.

PROBIOTICS
- Probiotics are live bacteria or yeasts that have health benefits when taken in sufficient amounts. They are found in foods such as yogurt and dietary
supplements. Hundreds of species of microbes live in the human intestines and nearly all are “Good” normal flora.
- When you buy a probiotic you do not know for sure whether the bacteria will live and be active.
- It is difficult to know the types and number of bacteria in the product and whether they are present in the recommended numbers
- You do not know, for the different bacteria, how long they live under different storage conditions and in different types of product
- You do not know exactly what protection the product will give you.

PREGNANCY
- Many women experience fluid loss due to “Morning Sickness” or periods of vomiting.
- The growing uterus crowds and displaces the intestines and with elevated progesterone the intestinal motility begins to slow.
- Resulting in decreased appetite, irregular food intake, and constipation.

PATHOLOGICAL CONDITIONS
- Neurological disorders that affect innervation of the lower GI tract
- Cognitive conditions that limit the ability to sense the urge to defecate
- Pain
- Immobility that leads to sluggish peristalsis
- Pathological conditions of the GI tract

FOOD ALLERGIES
- Common Food Allergies: Dairy Products, egg whites, shellfish, gluten, peanuts and other nuts, citrus fruits, and soy
- GI Symptoms of Allergies: Constipation, Diarrhea, red blistering rash around the anus, abdominal discomfort, bloating, excessive gas, and intestinal
bleeding.

BOWEL DIVERSION
- Bowel Diversion - is a surgically created opening for elimination of digestive waste products.
- A person with a bowel diversion does not eliminate via the anus.
- Effluent - is expelled through a surgically created opening in the abdominal wall called a stoma or ostomy.
- The Effluent may range from liquid to solid, depending on the part of the bowel that is being diverted.
- Temporary bowel diversions may be done to allow part of the intestine to rest and heal, after a surgical intervention for a benign condition of
the bowel.
 - Permanent bowel diversions are performed if the bowel is necrotic or cannot be salvaged because of severe disease or trauma.

ILEOSTOMY
- Ileostomy - brings a portion of the ileum through a surgical opening in the abdomen, bypassing the large intestine entirely.
- Most of the water is absorbed from the feces`in the large intestine, drainage at thai level is liquid and continuous.
- The patient must wear an ostomy appliance at all times to collect the drainage.
- Kock Pouch - creates an internal pouch, or reservoir, to collect ileal drainage
- To drain the pouch the patient inserts a tube through the external stoma into the pouch several times per day.
- This avoids continuous drainage, and the patient does not have to wear an ostomy appliance.
- Total Colectomy with Ileoanal Reservoir - is a surgical procedure in which the colon is removed, a puch is created from the ileum, and the ileum is
connected to the rectum.
- The patient evacuates the bowel on the commode in the usual manner.
- Feces is still liquid.

COLOSTOMY
- Colostomy - is a surgical procedure that brings a portion of the colon through a surgical opening in the abdomen
- Key Point: the location of the colostomy determines the consistency of the feces eliminated as well as the need to wear an ostomy appliance.
- The closer the colostomy is to the ascending colon and the ileocecal valve the more liquid and continuous the drainage will be.

- Colostomies near the rectum can often be controlled by diet and irrigation as a result the patient may not need to wear an ostomy appliance to
collect drainage.

- A colostomy created in the transverse colon is usually temporary and may be either a double barreled or loop colostomy.

- Double barreled colostomy has two separate stomas that externalize the bowel on both sides of the portion that has been removed.
- Proximal stoma is the functioning end that drains fecal material.
- The distal stoma may drain mucus and is sometimes called a mucous fistula

- Loop Colostomy consists of a segment of bowel brought out to the abdominal wall.
- The posterior wall of the bowel remains intact, but a plastic rod is wedged under the bowel to keep it from slipping back into the
abdomen. The anterior wall is incised, and the mucosal surface is left visible and open to air.

ASSESSMENT
- Normal Bowel Sounds
- High pitched, with approximately 5 to 15 gurgles a minute.

- Hyperactive Bowel Sounds

- Very high pitched and more frequent than normal.
- They may occur with small bowel obstruction and inflammatory disorders.
- They indicate hyperperistalsis, which can result in diarrhea.

- Hypoactive Bowel Sounds

- Low pitched, infrequent, and quiet
- A decrease in bowel sounds indicates decreased peristalsis, which can result in constipation.

- Absent Bowel Sounds

- If you hear no bowel sounds after listening in a quadrant for 3 to 5 minutes, you should listen in several areas before describing them as
absent.
- Absent bowel sounds indicate a lack of intestinal activity, which may occur after abdominal surgery.

DIAGNOSTIC TESTS
- Indirect Visualization Studies - Radiographic views of the lower GI Tract.
- Direct Visualization Studies - they are invasive procedures and are conducted by a gastroenterologist, who inserts various instruments to examine the
interior of the GI Tract.

LABORATORY STUDIES OF STOOL

- Stool specimens may be analyzed to detect blood, infection, or parasitic infection.
- The client must void first and then defecate into a clean, dry bedpan, bedside commode, or special container placed under the toilet seat.

HANDLING STOOL SPECIMENS

- Wear clean gloves when you handle the container or manipulate stool specimens.
- Use tongue blades to transfer the stool specimen to the container provided by the laboratory.
- Do not contaminate the outside of the container.
- Transport the specimen as soon as possible or consult the laboratory for appropriate storage.
TESTING FOR FECAL OCCULT BLOOD
- Blood from the Gi Tract may be visible to the eye or occult, especially when passed through the stool form higher up in the intestine.
- Guaiac or fecal occult blood test uses a reagent that detects the presence of peroxidase in stool.
- Screening can detect colorectal polyps so they can be removed before becoming cancerous.

ASSESSING FOR PINWORMS

- Pinworms are small, white, thread like worms that spread through human to human transmission:
- By ingesting infectious pinworm eggs
- By entry through the anus, by a person scratching the anus with pinworm eggs on their fingers
- Once present the pinworms live in the cecum they come to the anal area to deposit eggs during the night and migrate back up through the rectum during
the day.
- In assessing a child, you can spread the buttocks while the child is sleeping and examine the anus to see whether any pinworms are visible to the naked
eye.
- You can also test for the presence of the eggs with tape. In the morning, as soon as the patient awakens, press clear cellophane tape against the anal
opening. Remove the tape immediately and place it adhesive side down on a slide.
- You may also check at night by using a flashlight. The test may need to be repeated on consecutive days.

INTERVENTIONS / IMPLEMENTATION
PROMOTING NORMAL DEFECATION
PROVIDING PRIVACY
- Take a matter of fact approach this conveys to the patients that you are comfortable with this aspect of care.

- Provide Privacy for your patient when discussing or providing care related to bowel elimination. When assisting a patient with bowel elimination excuse
visitors from the room, draw the dividing curtains in shared rooms, and close the door.

- Control Odors because many patients are embarrassed by the odors of Bowel movements and therefore may ignore the urge to defecate.

ASSIST WITH POSITIONING

- When possible assist the patient to the bathroom to use the toilet
- Place a bedside commode next to the bed for patients who are unable to ambulate to the bathroom.
- A patient who must remain in bed should assume a semi fowler position to use the bedpan.
- Raise the siderails or provide an overhead trapeze so that the patient can grip them to maneuver on and off the bedpan.

SUPPORT HEALFUL INTAKE OF FOOD AND FLUIDS

- Diet Teaching the importance of a balanced diet promoting soft, formed, regular bowel movements
- Encouraging daily intake of 25 to 30 g of fiber to attract water into stool, and promote peristalsis.
- Key Point: adding fiber does not help to relieve opioid induced constipation unless the patient's current intake is actually deficient.

- Adequate fluid intake

- Water is preferred.

ENCOURAGE EXERCISE
- Encourage patients to exercise three to five times per week and to engage in daily walking or light activity.
- Assist patients to ambulate as soon as their condition permits.
- Provide a range of motion exercises for patients who must remain on bedrest.

ADMINISTERING ENEMAS
- Enema - is the introduction of solution into the rectum to soften feces and distend or irritate the colon in order to stimulate peristalsis and evacuation of
feces.
- Cleansing Enemas - promote removal of feces from the colon.
- Treat severe constipation or impaction
- Clear the colon in preparation for visualization procedures
- Empty the colon when starting a bowel training program
- Clear the colon for surgeries of the lower GI tract and for some pelvic surgeries.

- Retention Enemas - retention enemas introduce an absorption colon that is meant to be retained for a prolonged period.
- Nutritive Enemas - administer fluid and nutrition through the rectum for patients who are dehydrated and frail.
- Medicated Enemas - may be used to install antibiotics to treat infections in the rectum or anus or to introduce anthelmintic agents
for treatment of intestinal worms and parasites.
- Return Flow Enema
- Harris Flush may be ordered to help a patient expel flatus and relieve abdominal distention.

DIGITAL REMOVAL OF STOOL

- If fecal impaction does not respond to use of stool softeners and enemas, you will need to digitally remove feces from the rectum.
- Digital removal is accomplished by breaking up the hardened mass into pieces and manually extracting the pieces.
CARING FOR PATIENTS WITH DIVERSIONS
ASSESS THE OUTPUT
- Monitor the amount and type of drainage from the stoma.
- Presence of enzymes in the effluent increases the likelihood of skin breakdown.
- An ileostomy stoma is liquid and contains digestive enzymes.
- An ostomy lower in the GI Tract will have more solid output and fewer enzymes.

ASSESS THE SKIN

- Pay attention to the skin around the stoma for signs of irritation, redness, tenderness, and breakdown or drainage.

HELPING THE PATIENT ADAPT TO THE DIVERSION

- Ostomy patients no longer have sphincter control so they may need to modify their diet, by teaching and promoting diet modification and educating on
the effects of some foods on a patient with an ostomy.
- Ostomy care is a lifelong task.
- Your attitude and willingness to discuss body change will help your patient begin to adapt.
NURSING 103: CHAPTER 25 NOTES
URINARY ELIMINATION
- Urinary Elimination -

FUNCTION OF THE URINARY SYSTEM

- Body removes from food and fluids the nutrients necessary for essential bodily functions, such as physical activity, self repair, and mental operations.

THE KIDNEYS FILTER AND REGULATE

- Kidneys Filter
- Metabolic wastes, toxins, drugs, hormones, salts, and water from the bloodstream and excrete them as urine.
- Help Regulate
- Blood Volume, Blood Pressure, Electrolyte levels, and acid base balance by selectively reabsorbing water and other substances
- Secondary Functions of the Kidneys
- To produce red blood cells, secrete the enzyme renin, and activate vitamin D3

ANATOMY OF THE KIDNEYS

- The Kidneys are retroperitoneal, or located against the posterior abdominal wall behind the peritoneum.
- They are positioned under the 11th rib, extending from the T12 to the L3 vertebrae.

THE NEPHRONS FORM URINE

- Nephron - is the filtration unit of the kidney that is involved in the formation of the urine.
- Bowman Capsule - a double walled hollow capsule that encloses glomerulus.
- Glomerulus - a knotty ball of capillaries.
- Series of filtering tubules
- Loop of Henle
- Collecting Duct

- Together these structures act as a microscopic filter, controlling the excretion and retention of fluids and solutes to meet the body’s needs for fluid and
electrolyte balance.
TUBULAR REABSORPTION
- The Path of a Filtrate through a Tubule:
- Peritubular Capillaries
- Reabsorb 99% of the filtrate.
- Collecting Tubule
- 1% of filtrate returns, as urine, to the collecting tubule that transports it into the ureters.
- Distal Convoluted Tubule and Collecting Duct
- These are the final two segments within the nephron
- Distal convoluted tube finetunes filtration and regulates acid base balance by either reabsorbing or secreting water and
ions.

- Water and sodium are reabsorbed in these structures when antidiuretic Hormone and Aldosterone are Secreted.
- When the Amount of Fluid in the Body Decreases
- The Posterior pituitary Gland secretes more ADH.
- This causes the distal and collecting tubules to reabsorb more water into the blood.
- At the same time, the adrenal cortex secretes more aldosterone, which increases the reabsorption of sodium and water follows
sodium back into the blood
- ADH and ALdosterone thus have the effect of maintaining normal blood volume and blood pressure.

-When the Amount of Water in the Body Increases

- ADH is suppressed, and the opposite effect occurs.
- Urine becomes dilute, and water continues to be eliminated until its concentration returns to normal.
TUBULAR SECRETION
- They remove metabolic wastes from the blood into the urine
- They secrete hydrogen ions to help maintain the pH of Blood.

THE URETERS TRANSPORT URINE

- Each kidney has two ureters that transport urine from the renal pelvis to the urinary bladder
- A one way valve at the opening between the ureter and the bladder allows urine to enter the bladder and prevents backflow into the ureter.

URINARY BLADDER STORES URINE

- The Urinary Bladder - is a saclike organ that receives urine from the ureters and stores it until discharged from the body.
- The wall of the bladder consists of four layers:
- Innermost Mucous Membrane
- Seals off the remaining layers from exposure to urine

- Connective Tissue Layer

- Supports the mucous membrane

- Detrusor Muscle
- Composed of three layers of longitudinal and circular smooth muscle fibers

- Outermost Layer of Fibrous Connective Tissue

- Covers the detrusor layer

- The Average Bladder can store 500ml of Urine.

URETHRA TRANSPORTS URINE

- Urethra - transports urine from the bladder to the body's exterior.
- The mucous membrane of the urethra is continuous with the bladder and the ureters.
- Infection in the urethra can spread through the bladder and into the kidneys.

- Females:
- The urethra is about 3 to 4 cm long
- Opens at the Urinary meatus between the clitoris and the vaginal opening.
- Short, which can make women more prone to UTIs due to microorganisms residing in the vagina and rectum.

- Males:
- Extends about 20cm from the bladder to the urinary meatus at the distal end of the penis.
- The male urethra passes through the Prostate
- The male urethra also carries semen in addition to urine.
HOW DOES URINARY ELIMINATION OCCUR
- Internal Urethral Sphincter - is the thickening of smooth muscle where the bladder connected to the urethra.
- When closed the internal sphincter keeps urine in the bladder.
- When the bladder contains 200 to 450 ml of urine
1. Distention activates stretch receptors in the bladder wall.

2. Stretch receptors send sensory impulses to the voiding reflex center in the spinal cord.
3. Motor impulses cause the detrusor muscle to contract and the internal sphincter to relax for voiding. This triggers the unconscious
urge to void.

4. When the person is ready to urinate the brain signals the external sphincter to relax, allowing urine to flow through the urethra,
further contracting the detrusor muscle and forcing out any remaining urine.

5. After the detrusor muscle relaxes the bladder begins to fill with urine again.

NORMAL URINATION PATTERNS

- Kidneys produce about 50 to 60 ml of urine per hour, or 1500 ml per day.
- Most people void about 5 to 6 times a day.
- Frequent urination can be a sign of medical problem, such as diabetes or UTI
- Infrequent Urination can mean dehydration.

CHARACTERISTICS OF NORMAL URINE

- Specific Gravity - is a measure of dissolved solutes in a solution.
- As the concentration of the urine solutes increases the specific gravity increases.

- Specific gravity of water is 1.00 because there are no dissolved solutes.

- Key Point: The normal specific gravity range for urine is 1.002 to 1.030

- If fluid intake is low or there have been fluid losses, urine darkens as the specific gravity increases.

FACTORS THAT AFFECT URINARY ELIMINATION

DEVELOPMENTAL FACTORS
- Infants & Children
- A Newborn's normal specific gravity for urine is 1.008.

- Over the course of the first few weeks of life the urine becomes more concentrated, and a well hydrated infant produces 8 to 10
diapers a day.

- Infants do not voluntarily control voiding because neuromuscular functioning is immature.

- Most Parents begin toilet training when their children are between 18 and 36 months of age
- To begin toilet training toddlers must be able to control the external urethral sphincter, and have a sense of urge to void, and
communicate the need to use the toilet.

- Enuresis or occasional involuntary passage of urine is Normal In Children.

- Should be accepted Calmly.

- Nocturnal Enuresis or Bedwetting occurs in a few children aged 6 to 7 years.

- Nocturnal Enuresis is caused by insufficient level of ADH, pressure on the bladder, Urinary Infection, or Stress.

- Older Adults
- The Size and Functioning of the kidneys begin to decrease at about age 60 years and by age 75 years, typically only two thirds of the
nephrons remain functioning.

- This results in a decrease in filtration rate, and the ability to dilute and concentrate urine.
- Arteriosclerosis can reduce blood flow and impair the kidney's ability to filter toxins from the blood to excrete into the urine
- Drug toxicity is a risk due to decreased kidney function.

- Loss of elasticity and muscle tone in the bladder wall can lead to retention of urine or compromised bladder control

- Females: loss of abdominal and perineal muscle tone due to childbearing

- Males: prostate gland enlargement, which can lead to blockage of urine.

- Nocturnal frequency of urine

- Bladder infections due to incomplete bladder emptying

 - Leakage of urine

- Particularly in males, dribbling, urinary frequency, difficulty starting urination, and reduced force of the urinary stream.

- Retention of urine after voiding, which increases the risk of bladder infections.

PERSONAL / SOCIO CULTURAL / ENVIRONMENTAL FACTORS

- Anxiety
- A person who is anxious and tense may not be able to relax the abdominal and perineal muscles and the external urethral sphincter.
- Lack of Time
- Most people find it difficult to void when they feel rushed
- Ensure patients have enough time to relax fully.

- Lack of Privacy
- Many people require privacy for voiding.
- Some hospitalized clients may also avoid asking for assistance in the bathroom.
-
- Loss of Dignity
- Patients who need assistance with toileting may be especially vulnerable to such feelings, especially if they require catheterization or a
bedpan.
- Acknowledge such feelings and encourage the patient to participate in other aspects of self care, dressing and bathing.

- Cultural Influences
- Some patients will state personal, cultural, or religious requirements for toileting assistance to be provided by a person of the same gender, or
they will wait until a visit from a family member before acknowledging their need for help.

LIFESTYLE FACTORS
- Activity
- Kidneys conserve water when a person is dehydrated, concentrating urine.
- During prolonged periods of physical activity, or warm body temperature, the body loses sodium and other electrolytes rapidly through sweat.
- Electrolyte beverages may be more beneficial than plain water in helping prevent dehydration for prolonged, vigorous intensity
activity.
- Pale to clear urine indicates adequate hydration

- Caffeine
- Acts as a diuretic and increases urine production.
- Alcohol Consumption
- High alcohol intake impairs the release of ADH, resulting in increased production of urine.
- Diet
- A high salt diet causes water retention and decreased urine production.

MEDICATIONS
- Analgesics
- Phenazopyridine Hydrochloride (Pyridium), a bladder analgesic, turns urine a deep orange red color.
- Diuretics
- “Water Pills” treat blood pressure, fluid retention, and edema by increasing elimination of urine.
- Anticholinergics
- Promote urine retention by inhibiting involuntary contractions of the bladder, increasing bladder capacity, and delaying the urge to void for
those with urge incontinence.

- Antidepressants
- Reduce stress incontinence by relaxing bladder muscles. Some work by stimulating the nerve that controls the urethral sphincter.

- Antispasmodic
- Relaxes the bladder and prevents urge incontinence.

- Muscarinic Receptor Antagonists

- Block nerve receptors in the smooth muscle of the bladder. They control bladder contraction and reduce frequency for people suffering from
overactive bladder and urge incontinence.

- Estrogen
- Is used to improve blood flow to the urethral tissues and increase thickness of mucosal and urethral tissues.

- Botulinum Toxin
- Injections control spasms of overactive bladder by relaxing the muscles, especially when it occurs from nerve damage such as with spinal cord
injury or multiple sclerosis.

- Key Point: Some medications given for other than kidney conditions are nephrotoxic.
- These include some antibiotics, such as gentamicin and amphotericin B, and high doses or long term use of aspirin and ibuprofen.
SURGERY & ANESTHESIA
- Urinary tract surgeries can affect urine solutes, urine characteristics, and the ability to pass urine normally.
- Manipulation of the urinary tract frequently leads to trauma, bleeding, or the introduction of bacteria into a normally sterile tract
- Urine may be red or pink tinged after any invasive urinary tract surgery or procedure.

- Diagnostic and invasive procedures and childbirth can cause swelling and urinary retention.

- Surgery in the pubic area, vagina or rectum are associated with a higher chance of trauma to the urinary organs, lower abdominal swelling, loss of pelvic
muscle control, and increased pressure on the kidneys, ureters, or bladder.

- Surgery on the Reproductive Organs

- Usually require the use of an indwelling catheter for draining the bladder postoperatively.

- Anesthetic Agents
- Can decrease blood pressure and glomerular filtration
- Awareness to void can be decreased and lead to bladder distention.

PATHOLOGICAL CONDITIONS
- Infections or Inflammation
- Infections or inflammation of the bladder, ureters, or kidneys are UTIs

- Renal Calculi (Kidney Stones)

- Can obstruct the normal flow of urine.

- Hypertrophy (Excessive Growth)

- Hypertrophy of the Prostate gland, especially in older men, due to cancerous lesions, can interfere with the flow of urine from the bladder.

- Cardiovascular and Metabolic Disorders

- Decreased blood flow through the glomeruli and thus impair filtration and urine production.

- Nervous System
- Conditions that affect control of the urinary system organs will impair urinary elimination.
- Neurogenic Bladder - occurs as a result of impaired neurological function.
- The person cannot perceive bladder fullness or control the urinary sphincters.

- Systemic Infection
- Accompanied with High Fever, causes the kidneys to absorb and retain water.

- Immobility & Impaired Function

- Interferes with the ability to get to the bathroom in time or to communicate the need for assistance.
- Results in incontinence or urination in inappropriate settings or times.

- Cognitive Changes
- Altered perception of the urge to void or severe psychiatric conditions involving altered perception or ability to manage activities of daily living
may lead to incontinence.

ASSESSMENT
PHYSICAL ASSESSMENT
- Examination of the kidneys, bladder, urethra, and skin surrounding the genitals

DIAGNOSTIC PROCEDURES
- Blood Urea Nitrogen (BUN)
- Are used to assess renal function and hydration.

- System Direct Visualization Studies

- Tend to be invasive and require a consent form.

ASSESSING URINE
- Urine is an indicator for assessing hydration status as well as detecting or ruling out diseases or infections of the kidneys or urinary tract.
- Check for Color, Clarity, Odor, and Frequency of Urination.
INTERPRETING INTAKE & OUTPUT DATA
- Kidneys produce urine at a rate of approximately 50 to 60 ml per hour or 1,500 ml per day.
- Urinary output can fluctuate depending on:
- Quantity of fluids the patient drinks
- Ability of the heart to circulate the blood
- Kidney Functioning
- Amount of fluid excreted.

- Key Point: to interpret the meaning of fluid data, you must know the I&O and the patient's relevant physical condition.

MEASURING INTAKE AND OUTPUT

- Record All Fluids
- Patient drinks or receives intravenously
- Fluid Intake: oral fluids, semi liquid foods, ice chips, tube feedings, and irrigations instilled and not withdrawn immediately.
- Record Output
- Fluid Output: Urine output, gastrointestinal fluid loss, and drainage.

- Ensure Accuracy
- Explain to the patient, family members, and caregivers that I&O are being monitored.
- Post a sign at the bedside or on the door to the room as a reminder.
- Have the client assist you with monitoring urine output.

- Measure I&O
- You will usually total I&O at the end of each shift, as well as for each 24 hour period.

- Practice Asepsis
- When handling urine, observe universal precautions, wear disposable gloves, and avoid splashing the urine on yourself or objects in the room.

- Ambulatory Patients
- Explain you are monitoring their I&O
- Place a specimen “Hat” under the toilet seat to collect urine or have male patients void into a urinal.
- Periodically measure the output and empty the urine into the toilet.
- Provide support to patients with poor balance or weakness and encourage them to use safety rails when using a commode.

- Patients with Mobility Problems

- For patients whose movement is restricted or who have difficulty getting out of bed, use a bedpan or urinal to collect urine output.

- Urine From a Catheter

- Indwelling Urinary Catheter - is one that remains in the bladder for continuous drainage.
- It is held in place by a balloon that is inflated in the bladder above the detrusor muscle.
- Usually measure urine output from the indwelling catheter at the end of each shift unless otherwise prescribed.

OBTAINING SAMPLES FOR URINE STUDIES

- Freshly Voided Specimen
- When collecting a urine sample, pour the urine into a specimen container labeled with the patient's name, patient ID, Date of Birth, and Date
and Time of collection.
- Follow agency policy on additional packaging of specimens, and Transport the specimen to the laboratory as soon as possible.
- If there is a delay in getting the specimen to the laboratory, some agencies recommend refrigeration.

- Clean Catch Specimen

- The patient must cleanse the genitalia before voiding and collect the sample midstream because the initial flow of urine may contain
organisms from the urethral meatus, distal urethra, and perineum.

- Sterile Urine Specimen

- A sterile urine specimen aids in determining the presence of a UTI.
- You can obtain a sterile urine specimen by inserting a catheter into the bladder or by withdrawing a sample from an indwelling catheter.
- Do not take the specimen from the collection bag because that urine may be several hours old.
- Never disconnect the catheter from the drainage tube to obtain a sample. Interrupting the system creates a portal of entry for pathogens.

- 24 Hour Urine Collection

- 24 Hour urine collection may be prescribed to evaluate some renal disorders by showing kidney function at different times of the day and night.
You will need to use a large container and preserve all the urine.

ROUTINE URINALYSIS
- A Routine Urinalysis is commonly used as an overall screening test as well as an aid to diagnosing and monitoring several health conditions.

- Chemical Reagent Testing

- Thin, Plastic strips are dipped in the urine to detect specific substances that indicate kidney, urinary tract infection, or other
abnormalities.
- When the reagent comes in contact with urine, a chemical reaction causes a color change that you compare to a color chart.
SPECIFIC GRAVITY
- Specific Gravity - indicator of urine concentration, can be measure with a reagent strip
- Refractometer - measures the extent to which a beam of light changes direction when it passes through urine.
- The concentration of solids is high, the light is refracted more.

INTERVENTIONS & IMPLEMENTATION

PROVIDE PRIVACY
- Provide Privacy when discussing or providing care related to urination.
- Excuse visitors from the room, draw the dividing curtains in shared rooms, and close the door to the room.

- Give the patient privacy and time alone when possible to void.
- If the client is weak and a fall risk, you may need to remain with them.
- Taking a matter of fact approach condoms to patients that you are comfortable with this aspect of care.

ASSIST WITH POSITIONING

- Male: Assist the patient to the bathroom to use the toilet to allow him to assume his preferred position to empty his bladder.
- To place a urinal, position the patient in semi fowler's position with the legs slightly spread and penis into the urinal.
- Most men stand to void and may have difficulty voiding in other positions.
- Female: If a female patient must remain in bed, provide a bedpan. Place her in a semi fowler position to urinate unless contraindicated.
- Raise the siderails or provide an overhead trapeze so that the patient will have grip holds to maneuver herself onto and off the bedpan.
- Women generally find an upright seated or squatting position to be the most comfortable for voiding.

FACILITATE TOILETING ROUTINES

- Identify your patient’s pattern
- If you anticipate a change in pattern for elimination, inform the patient.
- If the patient is scheduled for a diagnostic procedure or activity, inform them ahead of time so they can void before the activity begins.
- Provide assistance
- Discuss with all unlicensed assistive personnel to offer assistance so there are less delays.

ASSIST WITH HYGIENE

- Urine is irritating to the skin
- Many patients are unable to do toilet self care, you may have to clean with warm soapy water over the genitals while the patient is seated on the toliet,
the bedside, or commode.
- Rinse with warm water because the soap can dry genital mucosa.

URINARY CATHETERIZATION
- Catheterization - is commonly used intervention, is the introduction of a pliable tube into the bladder to allow drainage of urine.
- Urinary Catheterization is used for the following:
- Obtain a sterile urine specimen
- Drain the bladder for surgical or diagnostic purposes
- Prevent or treat bladder overdistention and urinary retention
- Measure post void residual
- Protect excoriated skin from contact with urine
- Promote comfort by reducing the need for unnecessary movement of patients

- Self Catheterization
- Patients with spinal cord injuries or neurological disorders use intermittent catheterization to drain the bladder.

- Key Point: Intermittent catheterization carries a substantially lower risk of infection than does an indwelling catheter.

- Straight Catheter
- Is a single lumen tube that is inserted for immediate drainage of the bladder. After the bladder is empty or the sample obtained, the
catheter is removed and the patient resumes voiding independently.
- Indwelling Catheter
- Foley or Retention Catheter
- Is used for continuous bladder drainage.
- Double Lumen - is usually a double lumen tube: one lumen is used for urine drainage, and the second lumen is used to inflate a
balloon near the tip of the catheter.

- Triple Lumen - is used when the patient requires intermittent or continuous bladder irrigation, for which the third lumen is used.

- Inflated Balloon - holds the catheter in place at the neck of the bladder. The balloon is sized according to the volume of fluid used
to inflate it.

- Superpubic Catheter - is used for continuous urine drainage when the urethra must be bypassed.
- Is inserted through an incision above the symphysis pubis.
- It may be sutured in place initially.
- Once the stoma tract has healed, a standard indwelling catheter is usually used and held in place by inflation of the balloon.
URINARY CATHETER INSERTION
- Key Point: After considering alternatives for bladder drainage, indwelling urinary catheters may be used but should remain in place only as long as
absolutely necessary.
- The longer they are in place, the greater the risk of infection.

- To insert a urinary catheter, you will need to do the following:

- Always check for latex or teflon and iodine allergy before performing a catheterization.
- Explain to the patient the reason for the catheter insertion, the expected length of time the catheter will be needed, and the sensations they will
experience.
- Explain that when the catheter is inserted it may feel as though they are voiding, but the urine is going into the tube, not onto the bed.
- Use a dorsal recumbent position for female patients and supine for male patients.
- Cleaning around the meatus and perineum is mandatory before insertion of the catheter.

CARING FOR THE PATIENT WITH AN INDWELLING CATHETER

- Prevent Urinary Tract Infection
- Do not disconnect the tubing or open the drainage system
- Regularly check connections between the catheter and drainage tubing and the drainage and collection bag.
- If the system becomes disconnected, wipe both ends of the tubes with antiseptic before reconnecting them.
- After each bowel movement and if the catheter becomes soiled from drainage or feces, clean it with mild soap and water.
- Empty the collection bag at least every 8 hours.
- Do not touch the spout to any surfaces when emptying the collection bag.
- Keep the collection bag below the level of the bladder, but off the floor.
- Change indwelling catheter only when necessary
- Routine hygiene is all that is necessary for meatal cleansing.

- Maintain Free Flow of Urine

- Keep the tubing and bag below the bladder level
- If the collecting bag must be higher than the bladder clamp the catheter to prevent backflow.
- Frequently inspect the tubing to ensure that the urine flows freely.
- If urine is not flowing freely check to be sure the patient is not laying on tubing.

- Prevent Transmission of Infection

- Be sure to observe standard precautions
- Wear Gloves
- Always perform hand hygiene before and after providing care.

- Promote Normal Urine Production

- Encourage oral intake of at least 8 to 10 glasses
- Monitor I&O at least every 8 hours
- For accurate determination of output, empty the urine into a calibrated container
- Observe the urine output for color and characteristics.
- Encourage the patient to be active and out of bed as much as possible.

- Maintain Skin and Mucosal Integrity

- Secure the tubing to the patients thigh
- Assist with routine hygiene care as needed
- Avoid using powder or lotions in the perineal area
- Monitor urethral meatus and upper drainage tube.

BLADDER IRRIGATION
- Performed to maintain patency of a urinary catheter, or to wash out the bladder and other urological indications.
- Bladder irrigation is not beneficial for the prevention of CAUTI, and can have irritating effects and may lead to resistant microorganisms.

URINARY DIVERSION
- Urinary Diversion - or urostomy, is a surgically created opening for elimination of urine, required when the bladder must be removed or bypassed.
NURSING 103: CHAPTER 28 NOTES
PAIN
- Pain - is whatever the person says it is, and exists whenever the person says it does. It is an unpleasant sensory emotional experience associated with
actual or potential tissue damage or described in terms of such damage.

- The pain experience can significantly interfere with a person’s quality of life.

- Pain is protective, warning us of potential injury to the body.

- Recognizing types of pain can make pain management more effective.

ORIGIN OF PAIN
- Cutaneous / Superficial Pain - arises in the skin or the subcutaneous tissue.
- The injury is superficial, it may cause short term pain.

- Visceral Pain - is caused by the stimulation of deep internal pain receptors.

- It is most often experienced in the abdominal cavity, cranium, or thorax.
- Visceral pain is not well localized and can be described as tight, pressure, or crampy pain.
- Menstrual cramps, labor pain, gastrointestinal infections, bowel disorders, and organ cancers all produce visceral pain.

- Deep Somatic Pain

- Originates in the ligaments, tendons, nerves, blood vessels, and bones.
- Deep somatic pain is localized and can be described as tender or achy.
- Fracture or sprain, arthritis, and bone cancer can cause deep somatic pain.

- Radiating Pain
- Starts at the origin but extends to other locations

- Referred Pain
- Occurs in an area that is distant from the original site.

- Phantom Pain
- Is pain that is perceived to originate from an area that has been surgically removed.

- Psychogenic Pain
- Refers to pain that is believed to arise from the mind.
- The patient perceives the pain despite the fact that no physical cause can be identified.

CAUSE OF PAIN
- Physical pain is either nociceptive or neuropathic.

NOCICEPTIVE PAIN
- Nociceptive pain is the most common type of pain.

- It occurs when pain receptors respond to stimuli that are potentially damaging.

- Nociceptive pain results from injury to body tissues.

- Two types of nociceptive pain are:

- Visceral Pain - Pain originating from internal organs.

- Somatic Pain - pain originating from the skin, muscles, bones, or

connective tissue.

NEUROPATHIC PAIN
- Neuropathic pain is a complex and often chronic pain that arises when injury to one
or more nerves results in repeated transmission of pain signals even in the absence
of painful stimuli

- Neuropathic pain is described as burning, numbness, itching, and “pins and needles”
prickling pain.

- The nerve injury may originate from any of a variety of conditions, medications, such
as chemotherapeutic agents, can trigger nerve injuries that may cause neuropathic
pain even after the medication is discontinued.
DURATION OF PAIN
ACUTE PAIN
- Acute pain has a short duration and is generally rapid in onset.
- It varies in intensity and may last up to 6 months
- This pain is most frequently associated with injury or surgery.
- Although acute pain may absorb a patient's physical and emotional energy for a short time, it is helpful for the patient to know that it will generally
disappear as the tissues heal.

CHRONIC PAIN
- Chronic pain or persistent pain, lasts 3 to 6 months or longer and often interferes with daily activities.
- Persistent pain is often related to chronic illness, cancer, or musculoskeletal issues.
- Patients with chronic pain may experience periods of remission and exacerbation.
- People experiencing chronic pain fall more often, have sleep disturbances, and poor appetite, and have other impairments with ADLs
- They may also experience emotional distress, withdrawal, depression, anger, frustration, dependence, fatigue, and catastrophizing.
- Persistent Pain is the most feared aspect of cancer or other progressive diseases.

INTRACTABLE PAIN
- Intractable pain is both chronic and highly resistant relief.
- This type of pain is especially frustrating for the patient and care provider.

QUALITY OF PAIN
- Pain Quality - may be described as sharp or dull, aching, throbbing, stabbing, burning, ripping, searing, or tingling.
- Pain Periodicity - may be referred to as episodic, intermittent, or constant.
- Pain Intensity - is described with a variety of terms, such as mild, distracting, moderate, severe, or intolerable.

THE FUNCTION OF A PAIN RESPONSE

TRANSDUCTION
- Transduction - nociceptors become activated by the perception of potentially damaging mechanical, thermal, and chemical stimuli.
- Pain sensitive nociceptors are found in the skin, subcutaneous tissue, joints, and walls of the arteries.
- Painful stimuli prompt the release of substances that trigger release of inflammatory chemicals.
- These cause an injured area to become red, swollen, and hot.
- Inflammation is the most frequent cause of pain.

TRANSMISSION
- Transmission - Peripheral nerves carry the pain message to the dorsal horn of the spinal cord in a process.

TRANSMISSION TO THE SPINAL CORD

- Pain messages are conducted to the spinal cord along either of the two types of fiber:

- A - Delta Fibers - are large diameter myelinated fibers that transmit impulses at 6 to 31 meters per second.
- These fibers transmit fast pain impulses from acute, focused mechanical and thermal stimuli.

- C Fibers - are smaller, unmyelinated fibers that transmit slow pain impulses - that is, dull, diffuse pain impulses that travel at a slow rate.
- C fibers conduct pain from mechanical, thermal, and chemical stimuli.

TRANSMISSION TO THE BRAIN

- Pain transmission from the spinal cord involves endogenous chemicals called neurotransmitters.
- Most pain impulses are sent to the thalamus of the brain, which acts as an integrating center to
direct the impulses to three regions of the brain:
- Somatosensory cortex perceives and interprets physical sensations
- Limbic System is involved in emotional reactions to stimuli
- Frontal Cortex is involved in thought and reason. This is when the person perceives
pain.

PAIN PERCEPTION
- Perception - involves the recognition and definition of pain in the frontal cortex.
- Pain Threshold - is the point at which the brain recognizes and defines a stimulus as pain.
- The number and intensity of stimuli necessary to produce pain, as well as the duration
and characteristics of the pain produced varies from patient to patient.

- Pain Tolerance - is the duration or intensity of pain that a person can endure.
- This varies not only from person to person but also for the same person in different
situations.

- Hyperalgesia - Occurs when a person experiences a painful stimulus, but the response is greater than the expected level of pain.
- Increased pain perception may occur in the tissue where the initial injury took place and worsen over time.
- Hyperalgesia can be opioid induced. This occurs when the person experiences new or worsening pain as a result of taking opioids.
PAIN MODULATION
- Modulation - changes the perception of pain by either facilitating or inhibiting pain signals through the endogenous analgesia system and the gate
control mechanism.

THE ENDOGENOUS ANALGESIA SYSTEM

- Endogenous analgesia system - are neurons in the brainstem that activate descending nerve fibers to conduct impulses back to the spinal
cord.
- These impulses trigger the release of endogenous opioids and other substances to block the continuing pain impulses and provide
pain relief.

- Endogenous Opioids - are naturally occurring analgesic neurotransmitters that inhibit the transmission of pain impulses.
- Endogenous opioids bind to opiate receptor sites in the central and peripheral nervous systems at four receptor sites.
- Each of the receptor sites has a different affinity for various medications.
- Non Pharmacological measures can also promote the release of endogenous opioids.

THE GATE - CONTROL THEORY

- Pain impulses can also be modulated at the spinal level.
- Gate Control Theory of Pain Modulation - suggests that the perception of pain does not occur by direct stimulation of only nociceptors.
- Pain is perceived by interplay between two kinds of fibers:
- C Fibers (Small / Slow)
- C Fibers produce Pain, as slow pain impulses traveling along c fibers from the periphery to the brain, they encounter a
“gate” that either allows or blocks the transmission of pain sensation to the brain.
- If the source of stimulation is nonpainful, the gate would be blocked to feeling pain.

- A Delta Fibers (Large, Fast)

- A - delta fibers inhibit pain.
- Sensory impulses along fast A - Delta Fibers, which quickly excite inhibitory neurons at the “gate”
- These neurons in turn block some of the pain signals being carried along the slower C fibers.

FACTORS THAT INFLUENCE THE PAIN RESPONSE

- Key Point: Pain is universal, yet each person experiences and responds to pain differently as a result of the influence of emotions, age, sociocultural
factors, and communication and cognitive impairments.

EMOTIONS
- The most common emotions associated with pain are fear, guilt, anger, helplessness, and loneliness.

FEAR
- People fear that pain means illness or an injury is life threatening.
- Others may believe that they will be judged as weak or will become dependent on pain medications.
- When fears remain unresolved, a patient's pain can be prolonged or increased.

ANXIETY & DEPRESSION

- Anxiety and depression are common in people who are ill or hospitalized.
- Anxiety is most often associated with acute pain, but the anticipation of pain may also trigger anxiety.
- Depression is most often linked with persistent pain, especially intractable pain.
PREVIOUS PAIN EXPERIENCE
- People who have experienced pain may be more anxious about the possibility of experiencing pain and may also be more sensitive to pain.
- Patients who have had effective pain relief in the past are usually less anxious and are more confident that they will achieve satisfactory pain relief.
- Pain is usually a combination of physical and emotional experience.

LIFE STAGES
INFANTS & CHILDREN
- Newborns in the first month of life are frequently subjected to painful procedures, with the most immature infants receiving the highest number of painful
events.
- Key Point: Term newborns have the same sensitivity to pain as older infants and children, preterm infants may have greater sensitivity.

- Infants and small children usually respond to pain by crying

- Premature and term newborns experiencing pain do not always evoke detectable behavioral responses.
- Indicators of pain in neonates may be subtle.

OLDER ADULTS
- Some older adults may be unable to report pain because of cognitive impairment.
- Often their discomfort is evident only in nonverbal cues, or atypical behaviors, such as mental confusion or collapse.

SOCIOCULTURAL FACTORS
- We learn our responses to pain through interaction with family and social support groups.
- Key Point: do not assume that patients will react the same as others of the same ethnic or cultural group. Each patient is unique.
- Family and friends in pain have culturally specific responses to the patient's pain.
- Nurse’s too are affected by their culture.

COMMUNICATION AND COGNITIVE IMPAIRMENTS

- One of your greatest challenges as a nurse will be caring for patients in pain who have impaired cognition or communication.
- People with dementia might not appear to be experiencing pain, there is no evidence they have less pain than do other older adults.
- Cognitively impaired adults are not less sensitive to pain but rather may:
- Fail to interpret sensations that are painful
- Be unable to effectively communicate their pain to others.
- Be unable to recall their pain, while they nonetheless still experience it.

INDICATORS OF PAIN
- Decreased activity
- Crying
- Moaning
- Grimacing
- Frowning
- Irritability

- Less obvious indicators you may see in cognitively impaired patients include the following:
- Facial expressions
- Vocalizations
- Changes in physical activity
- Changes in routine
- Mental status changes
- Physiological cues
- Key Point: the absence of these cues does not mean that pain is absent.

HOW DOES THE BODY REACT TO PAIN

- The onset of acute pain activates the sympathetic nervous system.
- Flight or fight response is protective
- It minimizes blood loss, maintains perfusion to vital organs, prevents and fights infections and promotes healing.
- If the pain continues, the body adapts, and the parasympathetic nervous system takes over.
- Pain receptors continue to transmit the pain message so that the person remains aware of the tissue damage.
- The severity and duration of the pain significantly impacts the person's response to it.

UNRELIEVED PAIN
- Unrelieved pain can produce harmful effects in various body systems.

ENDOCRINE SYSTEM
- Ongoing pain triggers excessive release of hormones, including Adrenocorticotropic Hormone (ACTH)
- Cortisol, Antidiuretic Hormone (ADH), Growth Hormone (GH), Catecholamines, and glucagon.
- Insulin and testosterone levels decrease.
- The inflammatory process, combined with these endocrine and metabolic changes can result in weight loss, tachycardia, fever, increased respiratory
rate, and even death.
CARDIOVASCULAR
- Unrelieved pain leads to hypercoagulation and an increase in heart rate, blood pressure, cardiac workload, and oxygen demand.
- The combination of hypercoagulation and increased cardiac workload may lead to unstable angina (chest pain), intracoronary thrombosis (clot formation
in the vessels to the heart), and myocardial ischemia and infarction.

MUSCULOSKELETAL SYSTEM
- Uncontrolled pain causes impaired muscle function, fatigue, and immobility.
- Poorly controlled pain can prevent the patient from performing activities of daily living and engaging in physical therapy.

RESPIRATORY SYSTEM
- Pain tends to cause shallow breathing to limit thoracic and abdominal movement in an effort to reduce pain.
- Splinting - is when the body begins to use shallow breathing to limit thoracic and abdominal movement in an effort to reduce pain.
- Reduced tidal volume and increased inspiratory and expiratory pressures.

GENITOURINARY SYSTEM
- Unrelieved pain can release excessive amounts of catecholamines, aldosterone, ADH, Cortisol, angiotensin II, and Prostaglandins.
- Decreasing urinary output, urinary retention, fluid overload, hypokalemia, hypertension, and increased cardiac output.

GASTROINTESTINAL SYSTEM
- Response to pain, intestinal secretions and smooth muscle tone increase, and gastric emptying and motility decrease.

ASSESSING PAIN
- Key Point: To treat pain effectively you must first understand the patient’s perception of pain.
- Pain Location and Quality
- Pain Intensity
- Aggravating and Alleviating Factors
- Timing and Duration
- Pain Relief
- Questions that reveal the patient's ability to perform activities of daily living
- Mobility
- Psychological / social factors
- Key Point: You should make ongoing assessments regularly and, of course, accept the patient’s report of pain.
- Patient Self Report
- Is the most reliable indicator of pain.
- Inability to self report pain interferes with pain assessment
- Patients will be at risk for underrecognition and under or over treatment for pain.
- When pain is ongoing the autonomic nervous system eventually adapts, psychological and behavioral signs become less
noticeable
- Patient Satisfaction
- Regular ongoing pain assessments may indicate change in condition or a need for more aggressive pain management.
- Educate patients about pain management options and expected outcomes as you assess their responses to pain interventions.
-
PAIN THE FIFTH VITAL SIGN
- Key Point: The numerical rating scale is the most common method to assess pain.
- On admission to a healthcare facility
- Before and after each potentially painful procedure or treatment
- When the patient is at rest, as well as when involved in a nursing activity
- Before implementing a pain management intervention
- With each check of vital signs
- When the patient complains of pain.
- With a change in the patient's condition.

USING PAIN SCALES

- Select a pain scale by considering the patients age, level of education, language skills, eyesight, and developmental level.
- Numerical Rating Scale
- Numerical Rating Scale is numbered from 0 to 10, with 0 indicating no pain at all. Whereas a 10 indicates the worst possible pain.

- Visual Analog Scale

- Is a 10cm horizontal line with “No Pain” written on the left side and “Worst Pain Imaginable” written on the right.
- The patient points at the location on the line that reflects their current pain.

- The Simple Descriptor Scale

- A list of adjectives the describe different levels of pain intensity.
- It is time consuming to describe and may not be understood by many patients.
- Wong Baker FACES Pain Rating Scale
- FACES scale uses simple illustrations of faces to depict various levels of pain.
- It requires no numerical or reading skills.
- Useful with patients who are cognitively impaired or have difficulty communicating, and especially children older than 3 years of age.
ASSESSING PAIN IN INFANTS & CHILDREN
- When pain is not assessed properly the child's sleep suffers as well as performance in school, extracurricular activities, and day to day behavior.
- Consult the parents about the child's stress signals and reaction to pain
- Use art and play as ways to assess the child's understanding of pain and the pain management plan.
- Choose age appropriate toys to engage the child in acting out feelings

PATIENTS WHO ARE DIFFICULT TO ASSESS

- Key Point: the inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of an appropriate
pain relieving treatment.

- Patients With Dementia

- A person with dementia may not be able to elicit a reliable self report for pain, and their behavioral cues might not accurately reflect
the pain experience.

- Pain Assessment In Advanced Dementia (PAINAD)

- Is a five item observational tool, specifically geared to older adults with dementia.

- Patients With Developmental, Impaired Cognition or Communication

- Techniques to assess pain in individuals with cognitive impairment or developmental delay include
- Caregiver description
- Behavioral Pain Checklists
- Assessment Tools
- Pain Scales
- Report form Healthcare Team

- Patients With Mechanical Ventilation

- COMFORT Scale
- Is used to evaluate pain in mechanically ventilated pediatric patients.

NONVERBAL SIGNS OF PAIN

PHYSICAL INDICATORS
- Facial Expression, Posture, and Body position are reliable indicators of the intensity of pain.
- Basic and Common facial expressions that signal pain are lowering the brow, wincing, clenching jaws, and closing eyelids.
- Guarding a painful site or maintaining a tense position is also a sign of pain.

- Changes In Vital Signs Last Only A Short Time

- The body seeks equilibrium; thus after an hour or so the vital signs typically return to baseline even though the patient may still be in pain.
- Key Point: Normal vital signs do not mean that the patient is free of pain.

- Patients may be in pain even if they do not “Act Like” they are.
- Healthcare Professionals have been found to fail to assess pain and tend to underrate the pain the patient is experiencing.

EMOTIONAL INDICATORS
- Assess For Stoicism
- Some patients feel that they are being “bad” or “weak” if they express pain.
- Patients may withdraw or become stoic.
- Convey your concern and acknowledge their pain.

- Assess For Depression

- Patients with persistent pain are four times more likely to have depression than those without pain.

- Key Point: co occurring pain and depression create a vicious cycle whereby pain can lead to or worsen symptoms of depression, anxiety, and
irritability and then the resulting emotional response worsen the pain experience.

INTERVENTIONS FOR PAIN

- Each Situation is Unique
- The most effective and least invasive method of pain control is generally preferred.
- Remember to include nonpharmacological interventions when pain is chronic.
- The overall care of the patient depends on the cause of pain, whether pain is acute or chronic.
- For Acute Pain - Analgesic Administration, Pain Management.
- For Chronic Pain - Cognitive Restructuring, Pain Management, Coping Enhancement, Mood Management.

NON PHARMACOLOGICAL PAIN RELIEF MEASURES

- Non Pharmacological measures offer an alternative for people with mild to moderate pain who want to reduce use of analgesic drugs for pain relief.
- Holistic therapies can prompt release of endogenous opioids.
- Integrating non pharmacological measures, including complementary and alternative modalities into pain management plan may help ease persistent
pain and reduce the need for prescribed drugs
 - When providing non pharmacological pain relief measures:
- Assess your patient for openness to the therapy.
- Assess your patient thoroughly and often to determine whether the therapy is effective.
- Modify the pain management plan when the patient does not experience relief.
- Determine whether there is access to materials needed to perform nonpharmacological pain relief activities.
- Do not withhold analgesics when nonpharmacological methods are being used. In the case of mild pain, alternative therapy may be sufficient.

CUTANEOUS STIMULATION
- Cutaneous Stimulation is a pain relief method that utilizes skin stimulation to send impulses along the large sensory fibers which excite inhibitory
interneurons in the spinal cord to “close the gate.”
- Transcutaneous Electrical Nerve Stimulator (TENS) is a battery powered device that is worn externally, that utilizes electrode pads,
connecting wire, and the stimulator over the painful area to stimulate the A - Delta sensory fibers when activated.
- Percutaneous Electrical Stimulation (PENS) combines a TENS Unit with percutaneously placed needle probes to stimulate peripheral
sensory nerves.
- PENS is effective in short term management of acute and persistent pain.

COMPLEMENTARY AND ALTERNATIVE MODALITIES

- Spinal Cord Stimulator - Intractable spinal or limb pain is treated by a surgically implanted stimulator that interferes with the perception of pain.

- Acupuncture - is the application of extremely fine needles to specific sites in the body to relieve pain.
- Provides relief from joint skeletal, myofascial, and broad range of sources of pain and dental discomfort.
- Acupuncture can cause light headedness, which can lead to falls.

- Myofascial Release Therapy - or Active Release Therapy, is manual pressure applied to overused or injured muscles and nerves.
- Direct pressure loosens adhesions that develop from overuse.
- Tendonitis, Repetitive Motion Syndrome, Back Pain, Plantar Fascittis, Shin Splints, Strained Muscles can benefit from ART

- Massage - Provides cutaneous stimulation and relaxes the muscles to reduce pain.
- Effleurage - is the use of slow, long, guiding strokes to relax muscles, promote comfort, and reduce pain.
- Key Point: for most patients, superficial massage is soothing and relaxing, both mentally and physically. Some Patients do not like to be
touched therefore always obtain permission first.

- Low Level Laser Therapy (LLT) - or cold therapy is a noninvasive technique using low wattage light to penetrate deeply into tissue. This helps to
reduce acute or persistent pain by repairing tissue and minimizing inflammation caused by injury or arthritis.

- Temperature Therapy - the application of cold causes vasoconstriction and can help prevent swelling and bleeding.
- Cold helps to numb sharp pain and reduce inflammation and can be especially effective in reducing the amount of pain that occurs during
procedures.
- Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a washcloth, towel or fitted sleeve.
- Apply heat or cold intermittently, for no more than 15 minutes at a time, to avoid tissue injury.
- Check the skin frequently for extreme redness, blistering, cyanosis or blanching.
- If any of these occur, discontinue the treatment immediately and notify the provider.

- Contralateral Stimulation - stimulating the skin in an area opposite to the painful site.
- Stimulation may be in the form of scratching, rubbing, or applying heat or cold.
- This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast.

IMMOBILIZATION & TRACTION

- Immobilizing - stabilizing a painful body part with splints may offer some relief.
- It is particularly helpful with arthritic joints.
- The splints must be removed at regular intervals so that the patient can exercise the area to strengthen the site and prevent further injury.
- Patients in severe pain have the tendency to immobilize a painful area by limiting its use.

- Intermittent mechanical or manual traction - reduces pain resulting from compression on nerve tissue, especially in the spine.

COGNITIVE BEHAVIORAL INTERVENTIONS

- Cognitive Behavioral Interventions - attempts to alter patterns of negative thoughts and to encourage more adaptive thoughts, emotions, and actions.
- It is used to decrease depression and anxiety, both of which play a role in pain.

- Distraction
- You can use a distraction method of drawing the patients attention away from the pain by focusing on something other than the pain.
- It is based on the belief that the brain can process only so much information at one time.

- Relaxation Techniques
- Sequential Muscle Relaxation or progressive relaxation, is when the person sits comfortably and tenses a group of muscles for 15
seconds and then relaxes the muscles while breathing out.
 - Guided Imagery
- Using directed words and music, this technique evokes positive, calm imaginary scenarios that leads to relaxation and a positive,
focused state of mind.

- Guided imagery is a holistic technique that creates harmony between the mind and body promote feelings of well being elicit hope
and cope with pain

- Diaphragmatic Breathing
- Patients can be taught to use the diaphragm to intentionally take slow, even breaths when inhaling and exhaling at the rate of five to
eight breaths per minute.

- Hypnosis
- Involves the induction of a deeply relaxed state.
- The hypnotist offers therapeutic suggestions to provide relief of symptoms.
- Special training in hypnotherapy is required.

- Therapeutic Touch
- Is NOT Physical Touch
- It was developed by nurses and derived from the ancient practice of laying on hands
- Focuses on the use of the hands to direct energy fields surrounding the body.
- Research studies find results inconsistent, but some patients report being more relaxed and require less pain medication after a
session of TT.

- Humor
- This method has positive effects on a patient’s physical and emotional health.

- Laughter is positive and indicates mental well being.

- Humor may boost the immune system as well. It is especially helpful when used before a painful procedure because it lessens
anxiety and serves as a form of distraction.

- Expressive Writing
- Journaling, Blogging, and Storytelling can help the patient cope with persistent pain.
- Structured writing sessions in which the patient describes stressful events for a specified period of time over consecutive days.

- Animal - Assisted Therapy

- Animals trained to be obedient, calm, and comforting, provide therapeutic benefit to people with persistent pain and other health problems.
- Serum Cortisol levels decrease when they are exposed to therapy animals.

PHARMACOLOGICAL PAIN RELIEF MEASURES

- Analgesics - or pain relievers are classified into three groups: nonopioids, opioids, and adjuvants.
- Assess for pain and monitor the pain management plan regularly and continuously.
- Titrate medication based on valid and reliable pain assessment tools, and according to the patient’s response.
- Know the interactions and side effects of all the drugs recommended on each step.
- Understand that choice of treatment is based on the level of pain the patient is experiencing
- If the patient’s pain is not controlled, adjust the pain management plan accordingly.

DOSAGE AND ADMINISTRATION

- Key Point: analgesics work best if given before pain becomes too severe.
- Keeping ahead of the pain reduces suffering and helps patients to cope better and perform ADLs more independently.

NONOPIOID ANALGESICS
- Nonopioid Analgesics
- Relieve mild to moderate pain, reduce inflammation and fever.
- Nonopioid analgesics are often compounded with opioids

- Nonsteroidal Antiinflammatory Drugs

- The largest group of nonopioid analgesics is made up of nonsteroidal antiinflammatory drugs.
- Aspirin, Ibuprofen, naproxen, and Celecoxib.

- One of the most common side effects of NSAIDS is gastric irritation and Bleeding.

- To administer NSAIDs safely you should do the following:

- Taking NSAIDs with food, lowering the dose, or using enteric coated pills can reduce the incidence of GI bleeding.
- NSAIDs should be used with caution in patients who are taking anticoagulants or who have impaired blood clotting, renal disease, and GI
bleeding or ulcers.
- Some of the newer NSAIDs are less irritating to the GI system, so they cause less gastric irritation and bleeding.
- Combining two NSAIDs is not often recommended because it increases the risks of side effects and may not be more effective.
- Regular use of aspirin prolongs clotting time, so teach patients who use aspirin that they will bruise easily and will bleed more if cut.
- Key Point: Aspirin is a unique NSAID in addition to reducing inflammation, fever, and pain, it can also inhibit platelet aggregation the first step
in clot formation.
 - Acetaminophen
- Unlike most nonopioid analgesics, acetaminophen has little anti-inflammatory effect.
- Has analgesic and fever reducing properties
- Fewer side effects and is probably the safest of the nonopioids
- Does not affect platelet function, rarely causes GI problems, and can be used in patients who are allergic to aspirin or other NSAIDs

ADJUVANT ANALGESICS
- Adjuvant Analgesics - reduce the amount of opioid the patient requires.
- Primary therapy for mild pain
- Conjunction with opioids, for moderate to severe pain.
- Especially by patients experiencing significant side effects from increased doses of opioids
- Manage neuropathic pain

OPIOID ANALGESICS
- Opioid - are natural and synthetic compounds that relieve pain, although they vary in potency.
- Opioids work by binding with pain receptor sites to block the pain impulse.
- Opiate receptors include mu (μ), delta (δ), kappa (κ), and sigma (σ) receptors; however, mu receptors are most effective in relieving pain.
- Mu Agonist Opioids - stimulate mu receptors and are used for acute, chronic and cancer pain.
- Agonist - Antagonists are opioids that stimulate some opioid receptors but block others.
- They are appropriate for moderate to severe acute pain
- They should be given to patients taking mu agonists because they may act as antagonists at the mu receptor sites and reduce or
reverse the analgesia from the mu agonist.
- Commonly used medications include mixed agonist antagonists, such as pentazocine and nalbuphine, and partial agonists, such as
buprenorphine.

OPIOID EFFECTIVENESS
- Side effects:
- Nausea
- Vomiting
- Constipation
- Drowsiness
- Large Doses may lead to respiratory depression and hypotension
- Sedation is common at the beginning of opioid therapy or when the dose is increased
- Paradoxical reaction to opioids occurs when patients pain may actually increase despite receiving increasing doses of opioids.

EQUIANALGESIC
- Equianalgesic - refers to the approximately equal analgesia that a variety of opioids will provide.
- Equianalgesic dose calculations provide a starting point when changing from one opioid to another or from one route of administration to
another.

OPIOID ADMINISTRATION ROUTES

- Oral
- The Oral route is convenient and generally safe. It is the preferred route of administration unless rapid onset of analgesia is desired.
- Oral administration produces steady analgesic levels
- Use the oral route to provide relief of mild to severe pain.
- Nasal
- Rich Supply of blood in the drug with easy access to systemic circulation.
- The mixed agonist antagonist opioid butorphanol and the mu agonist sufentanil can be administered intranasally
- One draw to this route is that it may cause burning or stinging.

- Transdermal
- Transdermal administration is a convenient alternative for a patient who requires constant opioid treatment for pain; however, it does not
provide immediate relief.
- Transdermal Route delivers a continuous release of drug for up to 72 hours
- Fentanyl is commonly given as a transdermal patch.

- Rectal
- Suppositories are an excellent alternative to the oral route, especially in infants and young children.
- Effective when the patient is vomiting, has a GI obstruction, or is at risk for aspiration.

- Subcutaneous
- Subcutaneous administration may be used for intermittent injections and continuous administration of opioids.

- Intramuscular - IM injections are painful, the onset of action is slow, and absorption is unreliable.
- With repeated administration, sterile abscesses and fibrotic tissues can result.
- The IM route should be avoided if possible, but especially in children because they often refuse pain medication to avoid having an injection.

- Intravenous
- IV administration produces immediate pain relief and is desirable for acute or escalating pain.
- Most commonly used for short term therapy and for hospitalized patients who can be montored.
- Also used in the home care setting for patients with cancer and other pain who are unable to tolerate oral opioids.
NURSING 103: CHAPTER 9 NOTES
PSYCHOSOCIAL HEALTH & WELLNESS
- Key Point: Remember the physical body is only one dimension of a person. What patients think and feel is equally important to their healing process.

- Psychosocial - encompasses both psychological and social factors: a person’s psychological state interacts with their social development and position
within society to contribute to their overall or bio-psychosocial well being.

- Key Point: Any human dimension may dominate health needs at a given time.

PSYCHOSOCIAL THEORY
ERIKSON
- Assess for successful completion of developmental tasks.

MASLOW
- Developed a widely accepted hierarchy of human needs and motivations in which essential needs (Air, Water, and Food) must be met before higher
needs (Learning, creating, understanding, and self fulfillment.)
- Maslows’s hierarchy includes psychological, safety and security, love and belonging, self esteem, and self actualization needs.

SELF CONCEPT
- Self Concept - is one overall view of oneself.

- Key Point: self concept forms out of a person’s evaluation of his physical appearance, sexual performance, intellectual abilities, success in
the workplace, friendship and approval from others, problem solving and coping abilities, unique talents, and so on. A person with a healthy
self concept has a mostly positive perception of these evaluations of self.

- Self concept influences social functioning.

- Self concept is influenced by social functioning.

THE DYNAMIC SELF

- The self forms and changes in response to our environment.
- We discover who we are through a lifelong process of differentiating from and comparing yourself to others.
- Dynamic Self - develops as we experience life events, we continually reconstruct and develop our understanding of who we are.

FORMING SELF CONCEPT

- Humans are not born with a concept of self, rather it develops during infancy and childhood as the child interacts with family members, peers, and
others.
- Infant - learning that the physical self is different from the environment: “me” ; “Not Me”
- Child - Internalizing others’ attitudes about the self, primarily parents and peers: “who do they say that I am?”
- Child and Adults - internalizing standards of society; “How do I compare to others?”
- Adult - Self Actualization and self Adjustment: “this is who I am and who I will continue to be.”

- Change occurs gradually , and steps overlap.

FACTORS THAT AFFECT A PERSON’S SELF CONCEPT

- Some factors affecting a person’s self concept cannot be changed, for example gender, and developmental level.

- GENDER
- Certain aspects of self concept differ by gender, like role expectations of boys and girls rather than any actual difference in ability.

- DEVELOPMENTAL LEVEL
- As we mature, our self concept becomes more inner guided, that is others have less influence on our ideas about who we are.

- FAMILY AND PEER RELATIONSHIPS

- The family strongly influences a child’s developing self concept.
- An infant's sense of self permanence develops and becomes stable, categories of self begin to emerge.
- These include notions of gender, values, and a sense of having a distinct “place” among family members.
- Social identity is first fostered by interactions between infants and their parents and broden's in toddlerhood through relationships
with immediate and extended family members.
- Older children rely on peers than family in this respect.

- ILLNESS AND HOSPITALIZATION

- Illness, and hospitalization can have a depersonalizing effect that alters the self concept.
- The ill person may feel that they have become an object to be examined, poked, prodded, and discussed.

- LOCUS OF CONTROL
 - Internal influences help us to moderate self concept.
- Internal Locus of Control - is the inner “voice” people have that influences their self concept.
- Allowing people to feel they can control their lives, and take responsibility for their life experiences and for their
responses to them.
- This enables them to interpret unexpected adverse events in a more positive light.

- External Locus of Control - Is when people attribute their control of a situation to external factors, including other people,
institutions, and God.

COMPONENTS OF SELF CONCEPT

BODY IMAGE
- Body Image - is your mental image of your physical self,including physical appearance and physical functioning.
- Cognitive Understanding and Sensory Input influence body image.

- Cognitive Understanding is in turn influenced by family, social, ethnic, and cultural norms; education; and exposure to alternative
values.

- The American media portray the ideal male as young, tall, and muscular; men who do not match that ideal maintain a positive body
image through understanding that they are in good health, are attractive to their partners.

IDEAL, PERCEIVED, AND ACTUAL BODY IMAGE

- People may not see their own bodies as objectively as others see them.
- The closer the match between a person’s ideal body image and sensory input about his or her body, the more positive the person’s body image is likely
to be.

APPEARANCE AND FUNCTION

- Physical disability, such as blindness, deafness, or paraplegia, can interfere with the development of a positive body image.
- Children born with a physical disability are at risk for poor self concept and depression, perhaps related to the person’s perception that they have low
social value.

GRADUAL VERSUS SUDDEN BODY CHANGES

- Gradual changes in physical appearance occur naturally as the body matures and grows old.
- Most people adapt to these changes relatively easily, especially because their friends and colleagues are aging.
- In contrast changes in appearance or functioning occur abruptly, they are much more difficult to accept.
- Denial, anger, self hatred, and despair are a few of many reactions that can follow such an abrupt change in body image.

INFLUENCE OF BODY IMAGE ON HEALTH

- A negative body image has been associated with the following health problems:
- Depression
- Initiation of smoking among adolescents
- Increased risk of unintended pregnancy and sexually transmitted infections
- Increased incidences of being bullied.

ROLE PERFORMANCE
- Role Expectations - are the behaviors, attitudes, and traits that are considered appropriate for a person in a particular role or position.

- Role Performance - can be defined as the actions that a person takes and the behaviors that they demonstrate in fulfilling a role.
- Role Strain - is a mismatch between role expectations and role performance.

- Interpersonal Role Conflict - When the expectations of the role do not meet the expectations of others interpretations of the role.

- Inter Role Conflict - When two roles make competing demands on an individual, interrole conflict occurs.

PERSONAL IDENTITY
- Personal Identity - is your view of yourself as a unique human being, different and separate from all others.
- Identity develops over time beginning in childhood when you identify with your parents.
- Which is expected to change over time, personal identity is relatively constant and consistent.
- Cultural Identity is culturally determined and learned through socialization.
- People with a strong sense of personal identity are less likely to compare themselves to others or to be unduly influenced by them.
- They tend to appreciate the unique perspective and contributions of others yet value their own perspectives and contributions.
- People with a weak sense of personal identity have difficulty distinguishing their boundaries from those of others.
- They may interpret events in the environment personally, or interpret their personal experiences as belonging to everyone.

- Patients may experience an impaired sense of identity when they are challenged by a serious or chronic illness
- They then place too many limitations on their activities or interpret the responses of others in light of their illness.
SELF ESTEEM
- Self Esteem - is in the simplest terms, how well a person likes themself.
- It is the difference between the “Ideal Self” and “actual Self”
- “What I think I ought to be” and “What I really am”
- When we succeed beyond our ambitions, we experience a high sense of self esteem; when we aim for an ideal self beyond our capabilities,
we risk loss of self esteem.

- Key Point: The physical body is only one dimension of a person. Thinking and Feeling is equally important to the healing process.

- Key Point: Psychosocial problems involve nearly all areas of patient functioning. There is overlap between what we are calling psychosocial problems
here and the more specific problems of self concept, self esteem, anxiety and depression.

INTERVENTIONS FOR SELF CONCEPT & ESTEEM

PROMOTING POSITIVE BODY IMAGE
- A negative body image can contribute to broader self concept and self esteem issues, as well as to anxiety and depression.
- Encourage patients to discuss body changes resulting from their illness, surgery, or trauma.
- Provide the opportunity to interact with people who have had similar body changes.

- Healthy does not mean perfect, understanding that healthy bodies come in a wide range of shapes and sizes.
- Social media may portray the ideal body that is unrealistic and unhealthy for most people.

- Focus on activity and healthy eating, encourage clients to be active and focus on healthy eating rather than starving and depriving yourself to lose
weight.

- Do not make negative comments about your body, be conscious of negative comments that you make, avoiding talking negatively about body weight,
size, or deformity.

- Keep a List
- Keep a list of things you like about your body and refer to it when you're feeling down.

- Accept Compliments.
- Practice accepting positive comments about your appearance.

- Challenge Critical Comments, Practice challenging critical comments from others about your appearance.

- Surround yourself with positive people who support the changes you are trying to make in your image of your body.

- Use a counter and click it each time you make a deliberate effort to accept positive feedback about your body or engage in positive body behaviors.

FACILITATING ROLE ENHANCEMENT

- Help the client distinguish between ideal and actual role performance.
- Help the person identify their past, present, and future roles. For older adults, encourage reminiscence.

- Discuss Boundaries, expectations, and management defined by lifestyle and family networks.
- Facilitate communication between client and significant other regarding the sharing role responsibilities to accommodate role changes of the ill person.
- Help the client describe realistic roles and expectations tailored to specific health changes.
- Compare realistic roles with previous and less functional roles.
- Provide education about the difference between previous roles and current roles.
- Provide a learning environment that focuses on positive and supportive change.
- Help the client identify and role play behaviors needed in a role.

ANXIETY
- Anxiety ranges from normal to abnormal, depending on its intensity and duration.
- Mild Anxiety
- Normal anxiety in response to the events of day to day living.
- Heightens perception
- Sharpens the senses
- Enhances learning
- Enables the person to function at their optimal level

- Moderate Anxiety
- As anxiety increases, the perceptual field narrows
- The person begins to focus on self and the need to relieve their discomfort.

- Severe Anxiety
- Perceptual field is narrow: the person can focus on only one particular detail or may shift focus to many extraneous details.
- Focus is totally on self and the need to relieve the anxiety.
 - Panic Anxiety
- Becomes unreasonable and irrational
- Is unable to focus on even one detail in the environment
- May misperceive environmental cues
- May lose contact with reality.

COPING WITH ANXIETY

- Mild Anxiety
- Exercising
- Talking with others
- Engaging in pleasurable activities
- Deep breathing
- Relaxation programs
- Less Adaptive behaviors include:
- Sleeping, Eating, Smoking, Crying, Pacing, Fidgeting, Drinking, Laughing, Cursing, Nail Biting, or Finger Tapping.

- Severe Anxiety
- When anxiety is more severe, the person attempts to counteract the anxiety in some way.

DEFENSE MECHANISMS
- Defense Mechanisms - are unique patterns of coping with anxiety.
- Can be consciously or unconsciously used to relieve anxiety

- Denial - or refusing to acknowledge the existence of a real situation or associated feelings.

- Displacement - or transferring feelings from one target to another that seems less threatening.

- Overused defense mechanisms can be adaptive and lead to psychological disorders such as phobias, obsessive compulsive disorders ,and dissociative
disorders.

- Excessive or Unrelieved anxiety may contribute to the following:

- Psychosis or the loss of ability to differentiate self from nonself.
- Impaired reality testing or not knowing what is real and what exists only in one’s mind.

RELIEVING ANXIETY FOR PATIENTS WITH CONFUSION

- Gently hold or pat the patient's hand
- Realize that the person is probably and is doing the best they can.
- Be affectionate, reassuring, and calm, even when things make no sense.
- Respond to the person’s feelings instead of the content of their words.
- If the person has difficulty finding the right word, supply it for them unless doing so causes upset.
- If you do not understand what the patient is trying to say, ask them to point to it or describe it.
- Consider using alternative therapy, such as music therapy, that may be soothing to the patient.

DEPRESSION
- Key Point: As a nurse your independent role is not to diagnose and treat mental illness, but rather to assess and document the patient's behavioral state
as it relates to their medical surgical condition.

- Depression - commonly used to describe a feeling of sadness.

- Depressed mood most of the day nearly every day for at least 2 weeks, typically accompanied by markedly diminished interest or pleasure in
activities previously enjoyed.
- Symptoms of depression include the following:
- Insomnia or hypersomnia
- Loss of energy
- Feelings of worthlessness
- Diminished ability to concentrate
- Feelings of Emptiness
- Recurrent thoughts of death.

- Depression occurs in all age groups and is the leading cause of disability in the United States
- Affects 16.1 million american adults
- More prevalent in women than in men
- Suicide is the second leading cause of death in 15 to 29 year olds.

ASSESSMENT / INTERVENTIONS FOR OLDER ADULTS: DEPRESSION /DELIRIUM / OR DEMENTIA

DELIRIUM
- Delirium is an acute and potentially reversible disturbance of consciousness and cognition in response to underlying medical or mental illnesses,d rug
toxicity, and various other causes.
 - Delirium is an important consideration in quality of care and patient safety; an estimated 40% of cases are preventable.
- For patients with delirium, the nursing care focus is to keep the patient safe and to identify and allievate the source of the delirium.

DEMENTIA
- Dementia is an irreversible decline in mental abilities.
- The American Psychiatric Association defines dementia as part of neurocognitive disorders, a group of disorders in which the primary clinical deficit is in
cognitive function
- NCDs are acquired rather than developmental
- NCDs may be associated with Alzheimer disease, vascular disease, Parkinson disease, traumatic brain injury, HIV infection, or
substance/medication induced NCD.

- Dementia affects about 22% of adults aged 71 years and older.

- Prevalence increases with age; the rate is about 40% in those older than age 85 years.

- INTERVENTIONS FOR DEMENTIA

- Monitor the effectiveness and side effects of medications given specifically to improve cognitive function or delay cognitive decline.
- Provide appropriate cognitive enhancement techniques and social engagement.
- Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
- Avoid the use of physical and pharmacological restraints
- Maximize functional capacity, maintain mobility and encourage independence as long as possible.
- Address behavioral issues identify environmental triggers, medical conditions, or caregiver patient conflict that may be causing the behavior.
- Ensure a therapeutic and safe environment.
- Encourage and support advance care planning explain trajectory of progressive dementia, treatment options, and advance directives
- Provide caregiver education and support.
- Integrate community resources into the plan of care to meet patient and caregiver needs.

SUBSTANCE ABUSE AND MENTAL ILLNESS

- Substance abuse is a growing concern for the United States.
- People who regularly abuse drugs are also diagnosed with mental disorders.
- Mental illness and substance use disorders are among the leading causes of disability in the United States.
- Persons diagnosed with mood or anxiety disorders, antisocial personality, or conduct disorders are more likely to suffer also from drug abuse
or dependence.
- People diagnosed with drug disorders are roughly twice as likely to suffer from mood and anxiety disorders.
- A depressed patient who uses marijuana to numb the painful feelings]
- A depressed patient with low energy and lack of motivation who abuses adderall, cocaine, or crystal meth to increase the drive to get things
done.

- TREATMENT FOR SUBSTANCE ABUSE

- Treatment helps reduce the powerful effects of drugs on the body and brain, thereby helping people improve their physical health and
everyday functioning and regain control of their lives.
NURSING 103: CHAPTER 23 NOTES
CLASSIFYING DRUGS
- Drug - is a chemical that interacts with a living organism and alters its activity.

DRUG NAMES
- Chemical Name - is the exact description of the drug’s chemical composition and molecular structure.

- Generic Name - is assigned by the U.S. Adopted Names Council when developing manufacture is ready to market the drug.

- Official Name - is also the generic name that is listed in publications such as the United States Pharmacopeia National Formulary.

- Brand Name - is what the drug is sold as in stores.

- Prescription Drugs - require a written prescription from a healthcare provider who is licensed by the state to prescribe or dispense drugs.

DRUG CLASSIFICATIONS
- Basic Characteristics of Drugs include:
- Usage - Why is it being used
- Body System - where the drug affects.
- Chemical or Pharmacological class - what the drug is made of.

PROMOTING DRUG QUALITY AND SAFETY

- Key Point: When in doubt look it up.

- Pharmacopeia and Formularies - is the official recognized directory for drugs approved to be marketed in the U.S.
- Contains information on drug substances, composition, dosage forms, therapeutic values, and compounded preparations.

- Nursing Drug Handbooks - commercially published books are a quick reference source for drug dosages, side effects, and associated interventions.

- Pharmacology Texts - a textbook provides more information about physiology, pathophysiology, and mechanism of action, and drug classifications than
the drug formulary or a handbook.

- Electronic & Internet - Based Formularies - the internet, computer software, mobiles, other handheld devices offer convenient access to formulary
databases.

- Clinical Pharmacist - can assist you with medication related concerns.

- Medication Package Inserts - packaged with most medications, provides information similar to the drug formulary on that specific drug.

- Institutional Medication Policies and Procedures - Policies and protocols for medication administration for each institution may vary for certain drugs.

LEGAL CONSIDERATIONS
- U.S. The Food and Drug Administration (FDA) monitors the safety and effectiveness of medications available to consumers
- Regulates the testing, manufacture, and sale of all medications.

NURSE PRACTICE ACTS

- In most states a Nurse CAN NOT Administer medications without an authorized provider’s prescription.
- State boards regulate the types and routes of medications that can be administered by the various levels of nurses.
- Violation can result in disciplinary action or loss of license to practice nursing.

U.S. DRUG LEGISLATION

- Harrison Narcotics Act - regulates the manufacture, sale, and use of drugs that cause dependence (Opium, Cocaine, Marijuana.)
- Durham - Humphrey Amendment - Specified which drugs required a prescription and mandated the appropriate labeling.
- Comprehensive Drug Abuse Prevention and Control Act - regulated the manufacture, distribution and sale of controlled substances.

REGULATION OF CONTROLLED SUBSTANCES

- Controlled Substances - are drugs considered to have either limited medical use or high potential for abuse or addiction.
- Schedule I - That has a high potential for abuse and no acceptable medical use (Heroin, LSD, Ecstasy, Peyote, Mescaline.)
- Schedule II - Identifies drugs that have an acceptable medical use but a high potential for abuse (Cocaine, Morphine, Opium, Oxycodone.)
- Schedule III - Identifies medically acceptable drugs that may cause low physical, but high psychological dependence (Codeine, Hydrocodone)
- Schedule IV - Identifies medically acceptable drugs that may cause mild physical, or psychological dependence. (Xanax, Valium, Halcion)
- Schedule V- Identifies medically acceptable drugs with limited potential to cause dependence (Robitussin AC, Hydrochloride Atropine Sulfate)
- Controlled Substances must be double locked (Locked Drawers within in a Locked Area)
- A record of every dose administered must be kept.
STORING & DISTRIBUTING MEDICATIONS
- Stock Supply - (Bulk Quantity), labeled, and in a central location.

- Unit - Dose System - A locked, mobile cart is used, with drawers containing separate compartments for each patient's medications.
- Extra Drawers may contain supplies, medication cups, syringes and alcohol swabs.
- Unit Dose - is the prescribed amount of drug the patient receives at a single time.
- Key Point: Still check the dose and administration route and drug name before administering.

- Automated Dispensing System - Computerized system similar to a unit dose system, contains all the medications used on a particular nursing unit.
- Self Administration - patients self administer medications. Drugs are stored at bedside in individual containers.

PHARMACOKINETICS
- Pharmacokinetics - refers to the absorption, distribution, metabolism, and excretion of a drug.

DRUG ABSORPTION
- Absorption - refers to the movement of the drug from the site of administration into the bloodstream.
- The rate of absorption determines when the drug becomes available to exert its action.
- Bioavailability - refers to the proportion of a drug that enters the circulation and is able to have an active effect.
- Absorption depends on the following:
- Administration Route
- Form of the Drug
- Drug Solubility
- pH effects
- Blood Flow to the Area
- Surface Area

ROUTE OF ADMINISTRATION
- Local Effects - occurs at the site of application, resulting in little if any absorption.

- Systemic Effects - Drug is absorbed into the bloodstream before it can be distributed to distant locations.

- Key Point: Choice of Route is crucial in determining the suitability of the drug for a particular patient.

SOLUBILITY OF THE DRUG

- Solubility - Refers to the ability of a medication to be transformed into liquid form that can be absorbed into the bloodstream.
- Water Soluble Drugs - Drugs must be water soluble to dissolve in aqueous contents of the GI tract.

- Lipid Soluble Drugs - can penetrate lipid rich cell membranes and enter the cells.

- Enteric Coated Drugs - Cannot be broken down by gastric acids because the coating prevents the medication from being diluted before it
reaches the intestines. Prevents Stomach irritation.

- Time Released - Sustained Release is formulated to dissolve slowly, releasing small amounts for absorption over several hours.

PH & IONIZATION
- pH of the local environment also affects the absorption of a drug.
- Some drug’s molecules are in ionized form, and others are nonionized.

BLOOD FLOW TO THE AREA

- Medications are absorbed rapidly in areas where blood flow to the tissue is greatest.
- Excessive exercise draws blood away from the stomach and intestines to the muscles.
- The Intramuscular route would be better for the person who has recently engaged in heavy activity.

- A person in shock has poor peripheral circulation.

- IV route is more efficient for the person with poor circulation because drugs act more rapidly, even in healthy people.

DISTRIBUTION OF DRUGS THROUGHOUT THE BODY

- Distribution - is the transportation of a drug in body fluids to the various tissues and organs of the body.
- Target Area - the site where the drug effects occur.

- Distribution is influenced by the following:

- Adequate local blood flow.
- The permeability of capillaries to the drug’s molecules
- The Protein Binding capacity of the drug
LOCAL BLOOD FLOW
- The blood supply of the target site affects distribution of a drug.
- Factors that cause vasodilation in an area increase circulation to area tissues.
- Factors that cause vasoconstriction decrease circulation to the target tissue.

MEMBRANE PERMEABILITY
- Drug molecules must leave the blood and cross capillary membranes to reach their sites of action.
- The capillary networks in some organs consist of tightly packed endothelial cells that prevent some drugs from crossing them

PROTEIN BINDING
- Some molecules bind to plasma proteins and the remainder will be free.
- Only free unbound drug molecules can produce pharmacological effects because only free molecules can be metabolized or excreted.

DRUGS METABOLIZED IN THE BODY

- Metabolism - is the chemical inactivation of a drug through its conversion into a more water soluble compound or into metabolites that can be excreted
from the body.
- Key Point: Metabolism takes place mainly in the liver, but medications can be detoxified also in the kidneys, blood plasma, intestinal mucosa,
and lungs.

- If liver function is impaired the drug will be eliminated more slowly, and toxic levels may accumulate.

- First Pass Effect - When a medication becomes completely inactivated when passing through the liver.
- Oral medications are formulated with a higher concentration of the drug than are parenteral medications
- Some medications can be given parenterally, allowing the drug to be distributed directly to target sites before it passes through the liver.

DRUGS EXCRETED FROM THE BODY

- Excretion - when drug molecules must be removed from their sites of action and eliminated from the body.
- Kidneys
- - are the primary site of excretion.
- Adequate fluid intake facilitates renal excretion.
- If your patient has decreased renal function, monitor for medication toxicity.

- Liver & GI Tract

- Drugs broken down by the liver are excreted into the GI tract and eliminated in the feces.
- Others are reabsorbed by the bloodstream, distributed to the target site, and returned to the liver.
- Lungs
- Drugs removed by the lungs are not metabolized first.
- Gasses and Volatile liquids administered by inhalation usually are removed through exhalation.
- Other volatile substances, such as ethyl alcohol and paraldehyde, are highly soluble in blood and are excreted in limited amounts by
the lungs.
- Strenuous Exercise and Deep Breathing increase pulmonary blood flow and thereby promote excretion.
- Decreased Cardiac output and hypoventilation prolong the period of time for drug elimination
- Exocrine Glands
- Exocrine Glands - sweat and salivary glands.
- The elimination of metabolites in sweat is frequently responsible for such side effects as dermatitis.
- Drugs excreted in the saliva are usually swallowed and absorbed as other orally administered agents.

OTHER EFFECTS TO DRUG EFFECTIVENESS

- Onset of Action - the time needed for drug concentration to reach a high enough blood level for its effects to appear.

- Peak Action - when the concentration of medication is highest in the blood.

- Duration of Action - that period of time in which the medication has a pharmacological effect.

- Therapeutic Range - of a drug is a range of therapeutic concentrations.

- Therapeutic Level - is the concentration of a drug in the blood serum that produces the desired effect without toxicity.

- Peak Level - occurs when the drug is at its highest concentration

- Peak level must be measured when drug absorption is complete, and the drug is at its highest level in the patient's bloodstream.

- Trough Level - occurs when the drug is at its lowest concentration.

- Biological Half Life - is the amount of time it takes for half of the drug to be eliminated.
FACTORS THAT AFFECT PHARMACOKINETICS
- Age - Infants and young children need smaller doses because of their smaller body mass and immune body systems.

- Body Mass - the final concentration of a drug depends on the patient's body mass.
- A person who is much larger or smaller than the “average” requires an adjusted dose.

- Sex - men and women absorb drugs differently because women usually have lower muscle mass, a different hormone profile, and different fat and water
distribution.

- Pregnancy - drugs are contraindicated during pregnancy because of their possible adverse effects on the embryo or fetus.
- Teratogenic - are drugs that are known to cause developmental defects.

- Environment - heat and cold affect peripheral circulation, noisy environments may interfere with a person’s response to anti anxiety, sedative, or pain
medications.

- Route of Administration - influences the amount of drug absorption into the circulatory system and distribution to the sites of action.

- Timing of Administration - the presence or absence of food in the GI tract affects an oral drug’s pharmacokinetics. Biorhythms and cycles also
influence drug action.

- Fluids - insufficient fluid intake affects the absorption of solid dodge forms.

- Pathological States - intense pain decreases the effect of opioids, diseases causing circulatory, hepatic or renal dysfunction interfere with
pharmacokinetic process.

- Genetic Factors - Abnormal susceptibility to certain chemicals is genetically determined.

- Psychological Factors - some patients have the same response to a placebo - pharmacologically inactive substance - as they do to the active drug.

PHARMACODYNAMICS
- Pharmacodynamics - is the study of how medications achieve their effects at various sites in the body - how specific drug molecules interact with target
cells and how biological responses occur.

- Primary Therapeutic Effects - of medications are those that are predicted, intended, and desired.

- Palliative Effects - relieve the signs and symptoms of a disease but have no effect on the disease itself.

- Supportive Effects - support the integrity of body functions until other medications or treatments can become effective.

- Substitutive Effects - replace either body fluids or a chemical required by the body for improved functioning.

- Chemotherapeutic Effects - destroy disease producing microorganisms or body cells.

- Restorative Effects - return the body to or maintain the body at optimal levels of health.

- Secondary Effects - are unintended or nontherapeutic effects, are all effects other than the intended effect for which the drug was prescribed.

- Side Effects - are unintended often predictable physiological effects of the medication to which patients usually adapt.
- Common Side Effects Nausea, Vomiting, Dizziness, Diarrhea, Dry Mouth, Abdominal Distention, or Distress, and Constipation.

- Adverse Reactions - are harmful, unintended, usually unpredictable reactions to a drug administered at the normal dosage.

- Dose - Related - adverse reactions result from the known pharmacological effects of the medication.

- Patient Sensitivity - adverse reactions occur because the patient is usually susceptible to the effects of the drug.

- Toxic Reactions - are dangerous, damaging effects to an organ or tissue.

- Overdosing - administering a dose that exceeds the prescribed amount.

- Accumulation of the Drug In the Tissue - long term use or incomplete metabolism or excretion.

- Abnormal Sensitivity - or allergic response to the drug.

- Localized - to a particular tissue or organ or can also affect several organ systems.

- Reversible or Permanent - Causes permanent damage or reversible damage.

- Immediate and Evident - soon after administration, although they can take months or even years to develop.
 - Allergic Reactions - the immune system identifies a medication as a foreign substance that should be naturalized or destroyed.
- Allergic reactions range from minor to serious; even a small amount of a medication can cause a severe reaction.
- Urticaria (Hives), Pruritus (itching), Edema of soft tissue and mucosa, and Rhinitis (inflammation of the nasal mucosa) are
considered mild.
- Medications most frequently implicated in allergic reactions are antibiotics, biological agents, and diagnostic agents.

- Key Point: An anaphylactic reaction is a life threatening allergic reaction that occurs immediately after administration.

- Anaphylaxis produces sudden constriction of bronchioles, edema of the larynx and pharynx, severe shortness of breath, wheezing, and severe
hypotension.

- Immediate treatment includes discontinuing the medication and giving epinephrine, IV fluids, steroids, and antihistamines. Respiratory support
may also be required.
- A patient who is allergic to one drug may also be allergic to other medications in the same class.
- Always ask the patient about allergies and their reaction to the medications.

- Remember to document allergies in the patient's medical records, on the care plan, and on the MAR.

- People with severe allergic reactions should wear a medical alert bracelet that identifies the person and the allergen and should
carry epinephrine for emergency injection.

- Idiosyncratic Interactions
- Idiosyncratic Reaction - is an unexpected, abnormal, or peculiar response to a medication.

- Cumulative Effect
- Cumulative Effect - is the increased response to repeated doses of a drug that occurs when the rate of administration is greater than the rate
of metabolism and excretion.

MEDICATION INTERACTIONS
- Drug Interactions - occurs when one drug alters or modifies the action of another.

- Antagonistic Drug Relationship - Happens when one drug interferes with the actions of another and decreases the resultant drug effect.

- Synergistic Drug Relationship - is an additive effect. The effect of both drugs together is greater than the individual effects.

- Drug Incompatibilities - occur when multiple drugs are mixed together, causing a chemical deterioration of one or both drugs.

- You can usually recognize incompatibility when the mixed solution takes on a changed appearance.

- Drugs May Also Interact with Certain Foods

- High fat - foods and those low in fiber will delay stomach emptying and medication absorption by up to 2 hours.

- Acidic citrus fruits and juices enhance absorption of iron. Some citrus fruits, such as grapefruit, interact with medication in an antagonistic
manner.

- Carbonated Soft Drinks can cause medications to dissolve faster, be neutralized, or experience a change in absorption rate in the stomach.

- Dairy products taken with an antibiotic such as tetracycline decrease the absorption of the drug in the stomach.

- Foods containing tyramine when consumed while taking monoamine oxidase inhibitors, may produce a hypertensive crisis.
DRUG ABUSE OR MISUSE
- Tolerance - is a decreasing response to repeated doses of a medication.

- Dependence - is a person’s reliance on or need for the drug. It leads to compulsive patterns of drug use wherein the user lifestyle centers on procuring
and taking the drug.

- Drug Misuse - is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over the counter medications, and prescription drugs.

- Drug Abuse - is the inappropriate intake of a substance by amount, type, or situation, continuously or periodically.

- Illicit Drugs - street drugs, are drugs sold illegally. Many are prescription drugs sought for their mood altering effects.

MEASURE & CALCULATE DOSAGE

- Metric System - is the preferred system to measure drug dosage because it promotes accuracy by allowing for calculation of small drug dosages.

- Apothecary System - british apothecary system of measurement has been used in the U.S. since colonial times. Few medications are measured using
this system because it is less convenient and less precise.

- Household System - it is easier to teach a patient about home medications using this system, and can lead to medication dosing errors.

SPECIAL MEASUREMENTS
- Key Points: Note that units and mEq cannot be directly converted to the apothecary, metric, or household system.

- Units - are used to measure insulin

- The standard strength preparation of insulin is 100 international units.
- Key Point: Be aware that not all units are the same.

CALCULATING DOSAGES
The formula for calculating dosages:

Ordered Dose X Quantity on Hand = Desired Quantity

Dose on Hand

TYPES OF MEDICATION PRESCRIPTIONS

- Standard Written Prescriptions - apply without a renewal date until the prescriber writes a prescription to alter or discontinue the medication or
indicates a specific stop date on the original prescription.

- Automatic Stop Dates - are protocols that hospitals use for discontinuing medications after a certain length of time.

- STAT - prescription means that a single dose of a medication is to be given immediately and only once.

- Single - Prescription indicates that the medication is to be given only once at a specified time, usually before surgery or diagnostic procedures.

- Standing Prescription - occurs when a unit has a standard population of patients and the primary care provider develops a set of standing prescriptions
for treating a particular disease or set of symptoms.

- PRN Prescription - means the provider may prescribe a medication to be given whenever the patient requires.

- Key Point: The medication cannot be given more frequently than prescribed, even if symptoms persist.

COMMUNICATING MEDICATION PRESCRIPTIONS

- Written Prescriptions - handwritten on a prescription form or on preprinted standard medication order sheets and protocols.

- Verbal Prescriptions - which is an oral order spoken to a nurse.

- Write the prescription then sign it with the provider's name, followed by your name and credentials.
- Medication names sound the same and can be confusing and lead to administering the wrong drug.
- Repeat the prescription to the provider and spell the medication name to ensure accuracy.

- Telephone Prescriptions - verbal prescription via telephone usually in response to a call that is given to report change on a patient's condition or results
from a laboratory.
- The provider must co sign within 24 hours of prescribing.
- You should know and follow agency policy on telephone prescriptions.

IF A PRESCRIPTION IS INCORRECT
- Key Point: As a nurse, you are legally responsible for medications you administer.
- Look up the medication in a reliable source, verify spelling, usage, dosages, and routes.
- Ask another nurse or provider to check the prescription and compare it to your resource data.
- Contact the prescriber for clarifications, concerns, or questions.
MEDICATION ERRORS
- Medication Error - is any preventable event that may cause or lead to inappropriate medication use or harm to a patient.
- Each year 7,000 to 9,000 patient deaths in the U.S. are attributed to medication errors.
- Most Common Causes of Medication Errors are the Following:
- Lack of Knowledge of the Drug
- Lack of Information on the patient
- Unclear or Illegible order

ERROR PREVENTION TECHNOLOGY

- Computerized Prescriber Order Entry (CPOE) - helps prevent errors in orders and transcription due to incomplete and illegible handwritten
prescriptions.
- Safer, automatically alerts to possible interactions, allergies, and other potential problems.
- Bar Code Medication Administration - provides a highly effective system for identifying the right patient. Transfers data electronically, eliminating error
prone paper transcription.

- Smart Pumps - are iv infusion technologies used at the point of care to help you avoid programing errors and to ensure the correct dose is delivered to
the patient.

- Automated Dispensing Cabinets (ADCs) are computerized storage and drug distribution systems that minimize human handling of drugs in the
pharmacy.
- Reduce medication errors when the built in safety features are used.
WHAT TO DO IF A MEDICATION ERROR OCCURS
- Immediately assess the patient's vital signs and physical status for any changes.
- Report your findings to the patient's primary care provider.
- Follow your Institution's policy regarding incident reporting and other actions.
-

ENSURING SAFE MEDICATION ADMINISTRATION

THREE CHECKS
- Requires the Nurse to confirm the Proper Patient, Medication, and Dosage.
1) Before Preparing the Medication
2) After Preparing the Medication
3) At the Bedside before Administering it.

SIX RIGHTS OF MEDICATION

1. RIGHT DRUG
- Obviously, you must always administer the correct medication. That is one reason for reading each label three times.
1) Think Critically
2) Be aware of the pitfalls in abbreviations, units of measurement, and handwriting
3) Perform the “three checks” of the label against the MAR
4) Take special care with heparin
2. RIGHT DOSE
- Right dose is the prescribed dose for the particular patient
- Perform the “Three checks”
- For IV Medications, use smart infusion pumps to ensure the correct dose is delivered/
- Prepare the medication with precision because how you prepare it can affect the dose the patient receives.
- Read and write measurements carefully
- Write out “International Units”
- Know how and when to use a zero
- Always write zero before a decimal point
- Question prescriptions for multiple tablets or vials
- Question abrupt and excessive increases in dosage
- Question prescriptions that are not consistent with the standard protocol dosage range
- Examine the standards of care and practice in your institution

3. RIGHT TIME
- Check prescription against the time to give the drug, and document the exact time of administration on the MAR.
- If the drug is not documented, never assume the patient received it.
- As a rule, you can give scheduled medications within a “window” of one half hour before and one half hour after the scheduled time.
- Time oral medications in relation to food.
- Determine whether your patient is scheduled for any diagnostic procedures, surgery, or blood tests that require them to remain NPO.

4. RIGHT ROUTE
- Do Not Guess
- If information such as route, or dose aren't provided, clarify with the provider.
- The right route also includes the right site
- Use an Oral Syringe to draw up oral liquids
 5. RIGHT PATIENT
- Always double check the patients identification
- Do not leave medications at the bedside
- Be alert for patients with the same last names
- Ensure that the entry of prescriptions is made in the correct patient's medical record.

6. RIGHT DOCUMENTATION
- Name of medication given
- Dose of Medication Given
- Route of Administration and Injection Site for Parenteral Medications
- Date and Time Administered
- Your Name or Initials as Administering Nurse

- Key Point: You are responsible for documenting the clients responses to all medications, including therapeutic effects, side effects, and
unexpected or adverse reactions.

OTHER RIGHTS
- Right Reason - this includes the right to not receive unnecessary medications.

- Right to Know - you should tell the patient the name of the medication, why it's given, its actions, and potential side effects.

- Right to Refuse - the patient has the right to refuse medication regardless of their reasons and regardless of the consequences, except under certain
circumstances.

TWO IDENTIFIERS
- Full Name and Birthdate is stated by the patient while the nurse validates the information stated by the patient's ID Band.

ASSESSMENT FOR MEDICATIONS

- Before Medicating Patients:
- Measure vital signs
- Assess whether the patient’s general condition is appropriate for the medication
- Evaluate your knowledge of the medication.
- Identify biological factors that affect drug metabolism.

- While Administering Medications:

- Mental Status
- Coordination
- Ability to self administer the drug
- Swallowing

- After Medicating Patients

- Effectiveness of the Drug
- Side Effects
- Signs of Adverse reactions or toxicity

MEDICATION HISTORY
- Explore the patient’s allergy history.
- You should ask about the patient’s history of illness, medications, attitudes toward medications, learning needs, and whether the patient is pregnant or
breastfeeding.
- Check relevant laboratory test results and obtain a list of current medications and names of the prescribing providers.
- Some patients are noncompliant because they cannot afford the medications.

PHYSICAL EXAMINATION
- The physical examination helps you to identify potential problems and the need for adapting medication administration procedures.
- You will also assess relevant body systems and vital signs to confirm the need for the drug and to provide a baseline for evaluating the patient’s
responses.
- Oral medications, assess the patient’s ability to swallow; for IM medications, assess muscle mass.

RISK OF INJURY
- Risk for injury may be related to polypharmacy and misuse, overuse, or underuse of medications.
- Polypharmacy - is the ingestion of numerous medications in an attempt to treat many conditions simultaneously.
- Many people self prescribe or rely on OTC medications for symptom relief.
- They may continue taking them in combination with prescribed medications.
- In older adults the likelihood of increased sensitivity to medications, drug interactions, and adverse drug effects increases as the
number of medications taken increases.
 - Misuse, Overuse, Underuse
- Patients may misuse, overuse, underuse, or even contraindicate.
- Inconsistent dosage schedule hinders the body’s ability to achieve a therapeutic blood level of the medication.
- Certain drugs, like beta blockers can be dangerous or even life threatening when taken inconsistently.
NONADHERENCE
- Nonadherence - is the failure to follow a treatment plan or medication regimen.
- Patients maybe nonadherent for the following factors:
- Forgetfulness, intolerable side effects, inability to afford the medication, disagreement with treatment plan or lack of knowledge.

TEACHING SELF ADMINISTRATION

KNOWING & UNDERSTANDING WHAT YOUR TAKING
- When you are prescribed a new medication, ask why you are taking it.
- How long you should take it
- What Side Effects to expect
- Whether it can be taken with meals
- Any other special precautions
- Ask what each drug is for and what it does
- This can prevent taking two medications that do the same thing, as can occur when you are seeing multiple providers
- Keep a list of your medications including doses and times taken.
- Take this list with you when you visit any healthcare provider or emergency department.
- Take the drug for the entire length of time to receive its full benefit.
- This can lead to infection, or an antibiotic resistance may develop, leading to “superinfection” such as methicillin resistant staphylococcus
aureus.
- Older adults may forget to take their medications.
- A simple plan you can follow at home, such as a written schedule, meds calendar, or setting an alarm on a smart watch might help.
- If you cannot see well, have a family member write the schedule in large, black letters.
- Some older adults may take medications, only to forget shortly thereafter that they did so.

COMMUNICATE WITH YOUR PRESCRIBER

- Notify your prescriber if you have side effects, adverse reactions or questions.
- Wear a medical alert bracelet or necklace.
- Do not take medications prescribed to others.
- Use childproof caps
- Dispose of expired medications

ADMINISTER YOUR DRUGS CORRECTLY

- Read the label carefully on the bottle each time you take the medication so that you take the correct medication in the prescribed dose.
- Take only the amount and dose prescribed.
- To measure liquids, use kitchen measuring spoons rather than tableware, which can vary in volume.

STORE YOUR DRUGS SAFELY

- Do not store a drug in a different container from the one it came in.
- Store all medications in a dry place out of the sunlight and away from the heat.
- Medication requires cold storage, be sure you return it to the refrigerator immediately after use.

MAINTAIN YOUR SUPPLY

- Monitor your prescription amounts, and get refills before you run out.
- Check expiration dates and properly discard any outdated medications
- Do not take expired medications.

ADMINISTERING MEDICATIONS
ORAL MEDICATIONS
- Liquid Medications - Usually come in multidose bottles, required to be poured for individual doses into a disposable, calibrated cup.
- Liquid medications are frequently used for children and older adults.
- When pouring, hold the bottle so the liquid does not run over the label, and keep the cup at eye level on a flat surface when measuring.

BUCCAL & SUBLINGUAL MEDICATIONS

- Buccal Medications - are held in the cheek.

- Sublingual Medications - are held under the tongue.

ENTERAL MEDICATIONS (NASOGASTRIC & GASTROSTOMY)

- Enteral Medications - For patients who cannot swallow or have feeding tubes, you can give oral medications through Nasogastric, gastrostomy, or
jejunal tubes.
- Hydrophilic Medications - cannot be administered through feeding tubes because they attract water and will solidify in the tube.
 - Crushing Tablets - some should not be crushed, because crushing can change their action, always check.

- Continuous tube feedings - disconnect before giving medications.

- Eternal tube suction - discontinue suction for 30 minutes after administration and keep the tube clamped to allow time for the drug to be
absorbed.

SPECIAL SITUATIONS

- Patients Who Can't Swallow - Crush soluble tablets and place them in liquids or in a small amount of applesauce or pudding.

- Medications with Objectionable Taste - Have the patient suck on ice chips for several minutes before taking the medication to numb the taste buds.

TOPICAL MEDICATIONS
- Topical Medications - are applied directly to a body site or placed in body cavities by irrigation or installation.
- Local Effects - Is not absorbed through the skin and affects only the site that is applied.
- Systemic Effects - is absorbed through the skin and mucous membrane.

- Application should be with a Cotton Swab, Tongue Blade, or gloved finger to avoid absorption within the applicator's skin.

- Transdermal Medications - are prepared as patches made of a special membrane, that allow constant, controlled amounts of medications to be
released over 24 hours or more.

IRRIGATION & INSTILLATION MEDICATIONS

- Irrigation - is the washing out of a body cavity with a steady stream of fluid.
- Instillation - is the insertion into a body cavity of medication for retention or absorption.
- Remove Discharge or Foreign Bodies
- Apply Heat and Cold to an Area
- Apply medications
- Prepare an area for surgery
-
- Instillation and Irrigation medications may be used in the Eyes, Ears, Throat, Vagina, Rectum, Urinary Tract

OPHTHALMIC MEDICATIONS
- Ophthalmic ointments or solutions are used to treat eye infections and glaucoma.

OTIC MEDICATIONS
- Otic Medications are used to treat internal or external ear infections, to apply heat to the area, or to remove earwax.
- Use solutions at room temperature because a solution too hot or too cold can cause vertigo, nausea, and pain.
- To prevent infection, use sterile technique if the tympanic membrane has been ruptured or a surgical procedure was done.

NASAL MEDICATIONS
- Patients usually self administer nasal drops and sprays, many of which are available without a prescription.
- The most common nasal medications are used in the treatment of nasal congestion.
- Rebound Effect
- Caution patients that use long term use of decongestants may cause a rebound effect that requires continual use of the drug to
achieve nasal decongestant. The congestion is relieved but occurs again immediately after or when the effects of the drug wear off.

- Systemic Side Effects

- Frequent use of or swallowing excess decongestant can also cause systemic slide effects which can be serious in children; such as
Increased Heart Rate and Increased Blood Pressure.

VAGINAL MEDICATIONS
- Vaginal medications come in various forms, including foams, jellies, liquids, creams, tablets, and suppositories.
- Vaginal medications can be used for contraception, to destroy bacteria before gynecological surgery, reduce dryness or infection, or to induce labor.
- Keep suppositories firm, store them in the refrigerator before use.
- Foams and jellies are inserted using an applicator or inserter.
- Provide clean perineal pad to absorb drainage.

- Douche - is a vaginal irrigation using low pressure

- Douches are used to administer antimicrobial solutions, remove irritating discharge, or apply heat or cold to reduce inflammation.

- Key Point: Teach patients that douching can be harmful because it disturbs the normal pH and healthy balance of microorganisms in the
vagina. Research has shown a connection between douching and ovarian cancer.

RECTAL MEDICATIONS
- Rectal Suppositories and liquid instillations are used to encourage bowel movements or to treat systemic complaints such as nausea.
 - The rectal route may provide for higher blood levels of the medication than does the oral route because venous blood from the rectum does not pass
through the liver before entering the general circulation.
- Rectal medication can also be given in a colostomy stoma in certain patients.

INHALED MEDICATIONS
- Nebulization - is the production of fine spray, fog, powder, or mist from a liquid drug.

TYPES OF NEBULIZERS
1. Atomizer - disperse the medication in the form of large droplets.

2. Aerosol Sprayers - suspend the droplets of medication in a gas.

3. An Ultrasonic Nebulizer Mixes a small volume of medication, usually less than 1mL, with 3 mL of normal saline. The device forces air through the
nebulizer and delivers medication and humidity as a fine mist that can be inhaled deep into the lungs.

4. Metered Dose Inhaler is a type of nebulizer that delivers measured doses of a nebulized drug.
- MDI is a pressurized container prefilled with several doses of a durg and an eco-friendly substance to propel the medication forward.
- Medication is pumped into the extender instead of directly into the patient's mouth.
- Advantages
- High doses of medication can be rapidly instilled in the lungs, producing local effects directly in the airway avoiding systemic side
effects.

- Disadvantages
- Is that the person must have the manual dexterity and skill to coordinate the inhalation of the medication while pushing the canister
to administer the dose.
DRY POWDER INHALER (DPI)
- DPI is activated by a pump rather than by inhalation, the dose is loaded, and the patient simply takes a deep breath.

- Key Point: The only reliable method of determining the number of doses remaining in the canister is to subtract the number of doses used from the
number available.

PARENTERAL MEDICATIONS
- Parenteral Medications - are injected or infused into body tissues or into the bloodstream via, intradermal, subcutaneous, IM or IV routes.
- Requires the use of Aseptic Techniques since the skin is broken and susceptible to microorganisms.

- ADVANTAGES
- Absorbed Faster, and more completely
- More Predictable
- More Accurately Measured
- Can be used for Patients who can’t take Oral Medications.

- DISADVANTAGES
- Tissue damage may occur

NEEDLES
- Needles - are disposable, stainless steel sheaths that attach to a syringe.

- Gauges - the inside diameter of the needle lumen. Needle gauges are numbered 14 through 30
- Key Point: the smaller the gauge, the larger the diameter (14 gauge needle has a larger diameter than a 20 gauge needle.)
- Choose the Gauge based on the following:
1. Patient’s size and skin condition
2. Viscosity of medication used
3. Speed of administration desired

- Smaller Needles
- Cause less pain and trauma to the tissue.

- Larger Needles
- Used for blood and more viscous medications, to mix IV medications, or for rapid transfusion of IV medications.

- Bevel - is the sharp slanted tip of the needle that creates an opening to administer medications or withdraw blood.

- Long Bevel Tip - is sharper and narrower and causes less discomfort during injection.

- Short Bevels - are used for intradermal or IV injections.

- Needle Length - the distance from the hub of the needle to the tip is the needle length.

- Safety Needles
- Resheathing system with a sliding barrel that shields the needle
 - Syringes with retractable needles
- Needles with attached covers that reduce the risk of accidental puncture with contaminated needles.
SYRINGES
- Syringe - consists of a barrel, plunger, and syringe tip.

- Syringes are usually made of plastic and are disposable.

- Some have the needle attached; others do not.

- Luer Lock - Twist on Needle

- Non Luer Lock - slip on needle

- Standard Syringes - are supplied in 3 - 10 mL sizes and marked in 0.1 mL to 1 mL increments.

- Tuberculin Syringes - 1 mL capacity and are calibrated in 0.01 mL increments.

- Insulin syringes - are calibrated in units and are used to administer insulin.

- Key Points: Insulin syringes are marked in 100 units per milliliter.

- Prefilled Unit Dose System - are reusable syringe holders that hold disposable, single dose, prefilled medication cartridges.

- Disposable Prefilled, Self Contained Systems - injection plunger is attached to the medication barrel and twists in directly and reduces the risk of
dosing errors.

DRAWING UP & MIXING MEDICATIONS

- Ampule is a thin walled, disposable glass container with a narrow neck that you must snap off to access the medication.
- To prevent injuries, use an ampule opener to snap the glass
- Because glass fragments may be introduced into the medication, most agencies require you to use a filter needle or filter straw to draw up the
medication.

- Vial - single dose or multidose plastic or glass container with a rubber stopper that reseals the top after each needle introduction.
- Aseptic precautions are used to remove dust and rubber particles from the top of the vial.

RECONSTITUTING MEDICATIONS
- Medications that are not stable in solution are dispensed as powders in vials.
- Adding diluent or solvent to the powder to create a solution for injection.

MIXING MEDICATIONS IN THE SAME SYRINGE

- Two medications can be mixed into the same syringe
1. If they are compatible
2. If the total dose is within acceptable limits
3. If they are both prescribed by the same route.

- Is more efficient and utilizes less supplies.

- Maintain Sterile Technique.

- Do not contaminate one container with medication from the other container.

- Ensure the total, final dosage is correct by adding the volumes of the two medicines together before administering.

- Always check the compatibility before mixing medications together. If the contents of the syringe become discolored, visible particles are seen in the
solution, or there is change in consistency do NOT administer the medications.

NEEDLE “DEAD SPACE”

- Some believe adding 0.2 mL of air to the syringe measuring a medication for Intramuscular injection will allow or ensure all the medication is given and
none remains within the needle following the injection.

PREVENTING NEEDLESTICK INJURIES

- Jet Injectors - are needle free systems that drive liquid medication into the intradermal, subcutaneous, or intramuscular tissues by creating a narrow
stream under high pressure that penetrates the skin.
COMFORT & SAFETY CONSIDERATIONS
- Type, Viscosity, and Volume
- The Anatomical Landmarks
- Patients situation
- Injecting a large volume of medication into a small muscle causes pain and damage to the tissues.
- Injecting into the wrong tissue
- Incorrectly locating an injection site
- An unsteady needle and syringe

MINIMIZING DISCOMFORT
- Use the smallest needle suited
- Use two needles when drawing up medications
- Do not administer too much solution into an injection site
- Pull the skin taut, and insert the needle quickly
- Steady the syringe with one hand while injecting the medication
- Apply pressure
- Inject slowly
- Distract the patient from the procedure by talking to them
- Pat or hug a child after the injection
- Use other methods such as cooling the skin or flicking or tapping over the injection area before injecting, to distract the brain from the needle.

DISPOSING OF NEEDLES
- You Should NEVER recap a contaminated needle.
1. Place it uncapped, needle pointing downward, directly into a sharps disposal container.

SUBCUTANEOUS INJECTIONS
- Subcutaneous Injections - are given into the subcutaneous tissue, the layer of fat located below the dermis and above the muscle tissue.
- Subcutaneous injection absorption is slower than Intramuscular.
- Speed of absorption with each site varies:
- Absorption is fastest in the abdomen and arms.
- Absorption is slowest on the thigh and upper buttocks.
- Medication is absorbed more evenly, from the abdomen.

CHOOSING A SUBCUTANEOUS SITE

- Avoid the following sites:
1. Beneath Burns, Birthmarks, Scars, or Inflamed Tissue
2. Lesions
3. Bony prominences or lage underlying vessels or nerves

- When using the abdominal site, do not inject any closer than 5 cm to the umbilicus.
- For repeated injections should be an inch apart
- Rotate sites for repeated injections to minimize scarring and hardening of fatty tissue

CHOOSING A SUBCUTANEOUS NEEDLE

- Needle Length
- ⅜ to ⅝ inch needle is preferred.

- Needle Gauge
- Typically a 25 to 27 gauge needle is used.
ADMINISTERING INSULIN
- Route of Administration
- Insulin must be administered subcutaneously or intravenously because it is a protein and would be destroyed by the GI Tract.

- Syringes and Vials

- Insulin is administered using a special insulin syringe. Insulin vials contain 100 units/ml

- Dose Prescribed In Units

- The prescriber will specify the number of units of insulin to administer.

- Timing of Administration
- Insulin may be routinely prescribed in specific dosages at specific times or on a sliding scale, in which the dosage prescribed is based on the
patients blood glucose level.

- Categories of Insulin
- Basal Insulin - is given to cover the body’s energy needs without taking the diet into account.
- Common basal insulins are NPH, insulin glargine, and insulin detemir.

- Prandial - (Mealtime) or regular insulin is given to prevent high blood sugar after eating a meal.
- Insulin Aspart, and Insulin Glulisine.

- Combination Insulin - are manufactured mixtures of fast acting and long lasting insulin. These types of insulin result in fewer injections but
require careful monitoring.
- You can mix two different insulins in the same syringe so the patient can receive only one injection.

- Insulin Injectors
- Automatic Injectors
- Pressing a button on the device the injector releases the needle into the skin, releasing the insulin dose.

- Insulin Pump
- Maintains glycemic control because of the benefit of fine tuning dosing.
- The pump consists of a tube with a needle on the end of it that is taped to the abdomen, and a computerized device that is worn at
the waist.
- Insulin is received continuously from the pump.

- Insulin Pen Devices

- Contain a cartridge and disposable needles to deliver certain doses with each injection.
- They are convenient and may help patients to avoid medication errors.

- Non Disposable Syringes

- Used repeatedly if they are sterilized after each use.

- Spray Injectors
- Forcefully spray the insulin dose into the skin.
- Involves a wider area of skin than would a regular injection.
ADMINISTERING HEPARIN
- Heparin is a fast acting medication that interrupts the blood clotting process.

- Heparin dosage is based on the patient's weight and results of blood coagulation studies, so always check laboratory values for coagulation studies
before giving.

- Heparin is administered intravenously or subcutaneously because it is poorly absorbed from the GI tract.

- Administer the injection deep into the subcutaneous tissue of the abdomen.
INTRADERMAL INJECTIONS
- Intradermal Injections are given into the dermis, which is the layer of the skin located beneath the skin surface.
- Give small amounts of medications by this route
- Use a 1 mL syringe and a short, (26 - 28 gauge) small needle
- Insert at an angle of 5 to 15 degrees

- Do not apply pressure or massage the injection site, because the capillaries in the dermal tissue will quickly absorb the medication.

INTRAMUSCULAR INJECTIONS
- Intramuscular Injections - injections that are given into the muscular tissue.
- Absorbed faster than subcutaneous medications because of the rich blood supply in the muscles.
- Aspiration is used to ensure that the tip of the needle is in the muscle and not in a blood vessel.
- Key Point: Determine the safety of the drug in deciding whether to aspirate.
- Aspiration is not recommended in the vastus lateralis and deltoid muscles, or in children.

CHOOSING AN INTRAMUSCULAR SITE

- A safe distance from nerves, large blood vessels, and bones
- Free from injury, abbess, tenderness, necrosis, abrasion, or other pathology.
- Large enough to accommodate the volume of medication to be administered

CHOOSING AN INTRAMUSCULAR NEEDLE

- 1 or 1 ½ inch needle is considered standard
- 21 - 25 gauge needles are recommended for Intramuscular use.
- In the Deltoid Muscle use a 23 or 25 gauge, 1 inch needle.
- For a very thin person, you could use a 1 inch needle, even when injecting into larger muscles.
- For an obese person you may need a needle as long as 3 inches to penetrate the adipose tissue.

DELTOID SITE
- Located in the middle third of the upper arm.
- Should only be used for small amounts of up to 1 mL or when other sites are inaccessible.
- Avoid using it in infants, and assess children for adequate muscle mass.

VASTUS LATERALIS SITE

- Vastus Lateralis - located in the anterolateral thigh
- Preferred site for young infants, particularly before walking age
- Rapidly absorbed
- Larger volume of medication can be tolerated
- Good site for self administered medications
Z - TRACK TECHNIQUE
- Z track Technique seals the needle track and prevents medication from leaking out of the muscle up through the needle track and into the subcutaneous
tissues after the needle is withdrawn.

- Z track method is recommended for all IM injections, because it is less painful and helps to prevent irritation of the subcutaneous tissues.
INTRAVENOUS MEDICATIONS
- IV Medications - are given through a catheter, or cannula, inserted into a vein.
- Medication onset takes place within seconds
- Without a known antidote there is no way to prevent an adverse reaction if one occurs.

IV PUSH MEDICATIONS
- IV Push (Bolus) - Medications are injected directly into a vein and enter the systemic circulation immediately.
- Key Point: Many IV push medications are irritating to vein walls and can cause damage if accidentally injected into tissues.
- Assess Patient before, during and after giving the medication.
- Determine the compatibility of the drug with the IV fluid that is infusing and the plastic IV bag and tubing.
- Use Sterile Technique.
- Administer the Medication slowly.
- Observe the patient carefully for signs of adverse reactions.
- Have an antidote on hand if the drug has potentially serious side effects.
- If your patient shows signs of serious allergic reaction, Support the patient's airway, deliver oxygen, and administer medication to
reduce the reaction.

ADDING MEDICATIONS TO IV BAGS

- Advantage
- Useful when the drug can be infused continuously to achieve the desired effect.
- Disadvantage
- Danger of infusing too much fluid, especially for children, older adults, and people with cardiac or renal disease.

INTERMITTENT INFUSION
- Many medications, such as antibiotics are administered intravenously by intermittent infusion.
- Intermittent infusions may be given through the port of an infusing iv line or through an injection port called a saline or heparin lock.

- Infusion Setup
- Most intermittent infusion bags contain 50 to 250 ml of 5% Dextrose in water (D5W) or normal saline (0.9% NaCl).

- The drug is given over time, usually 30 mins to 60 mins in regular intervals.

- Piggyback Setup - is when a small bag of the diluted medication (Secondary Bag) is attached to the primary IV infusion line for
administration.

- Central Venous Access Devices

- IV medication is delivered through a central or peripheral vein.
- Give long term IV therapy
- Provide total parenteral nutrition when the patient cannot eat normally
- Have blood drawn without the trauma and complications of repeated venipunctures
- Provide vascular access when peripheral IV placement is difficult.
NURSING 103: CHAPTER 31 NOTES
SLEEP & REST
- Rest - is a condition in which the body is inactive or engaging in mild activity, after which the person feels refreshed.

- Sleep - is a cyclically occurring state of decreased motor activity and perception.

- A sleeping person is unaware of the environment and responds selectively to external stimuli.

IMPORTANCE OF SLEEP
- We spend more time sleeping than in any other activity.
- Poor quality or insufficient length of sleep for one night or even long periods of sleep deprivation can result in stress related illnesses.
- Sleep affects almost every tissue in our bodies
- Sleep also strengthens the immune system to help the body fight infection.
- Lack of sleep increases chances of heart disease, stroke, infections, and even cancer.
- Sleep is an important regulator of energy metabolism
- Total energy output is reduced during sleep, giving the body opportunity tot repair and restore.
- The body is less able to tolerate glucose and yet responds with insulin resistance.
- Not enough sleep leads to reduced energy expenditure, obesity, and type 2 diabetes.
- Too much sleep can lead to depression, anxiety, sedentary lifestyle, habitual late sleeping, and poor dietary habits.

- Sleep may improve learning and adaptation.

- Sleep and dreaming facilitate the storage of long term memory by assisting the brain in reorganizing and storing information.
- Adequate sleep helps to improve processing of information, increase attention and creativity, and aid in decision making.

- Sleep also appears to reduce stress and anxiety improving coping and concentration on activities of daily living

- More sleep also reduces the body’s sensitivity to pain.

- Sleep / rest and illness are interrelated.
- Illness and injury increase the need to sleep and at the same time make it difficult to sleep.
- Lack of sleep increases the susceptibility to illness by compromising the immune system.
- People who are ill or experience pain need more sleep to restore energy needed for tissue repair and healing.
STANDARD AMOUNT OF SLEEP
- Key Point: Sleep needs vary widely among individuals. Even though the accepted standard has been 7 to 9 hours per night for adults, there is no
definite amount or pattern of sleep that is best suited for all people.

AGE GROUP HOURS PER DAY SLEEP RELATED CONSIDERATIONS

- Sleep occurs in short periods of 2 -4 hours at a time.

- Sleep cycles are not related to circadian rhythm
New Borns 15 - 18
- Premature infants sleep more.
- Colic infants sleep less.

- Sleep wake patterns begin at about 6 weeks of age.

Infants 12 - 16 - Day Night Confusion Ends
- In the first year, most will nap in the morning and afternoon.

- By 18 - 21 months, most take only one nap per day.

Toddlers 11 - 14 - Most infants sleep several hours during the overnight period, with
morning and afternoon naps each day.

- Children with insufficient sleep experience have problems with

behavior, coping, school performance, as well as health risks
School Age 9 - 12 - Children who do not get enough sleep are more likely to show less
interest in learning new things, have higher odds of not doing
homework, and are more likely to care less about doing well in school.

- Screen time and technology use commonly interfere with sufficient

sleep
Adolescents 8 - 10
- Sleepier teens are more likely to fail to stay calm when faced with a
challenge. They are also less likely to perform well academically.

- In some cultures, total sleep time is divided into an overnight sleep

period and a midafternoon nap.
Young and Middle Adults 7-8
- Hormone changes with menopause commonly interfere with quality
sleep.

- Sleep may be more fragmented with rest or nap during the day.
- About half of those 60 years or older take longer to fall asleep, wake
up too often, or have a hard time staying asleep.
- Frequent waking is commonly due to physical discomfort, anxiety, and
Older Adults 7-9 nocturia.
- If sleep is interrupted, older adults may experience fatigue, irritability,
and impaired cognition.
- Older adults are more likely to suffer from obstructive sleep apnea,
restless leg syndrome, or periodic limb movement disorder.
PHYSIOLOGY OF SLEEP
- Synchrony - occurs when something happens at the same time or works or develops on the same time scale as something else.

CIRCADIAN RHYTHMS & SLEEP

- Biorhythms - are biological clocks that are controlled within the body and synchronized with environmental factors.
- Biorhythms influence many physical and mental functions
- Body temperature is lowest when the person wakes up in the morning
- Female menstruation follows an approximately 28 day cycle

- Circadian Rhythm - is a biorhythm based on the day - night pattern in a 24 hour cycle.
- Circadian rhythm is regulated by a cluster of cells in the hypothalamus of the brainstem that respond to changing levels of light.
- Most people have higher energy levels in the daytime and less energy at night
- Some people can be more alert and active in the morning while others are more active in the afternoon and evening.
- Key Point: Sleep quality is best when the time at which you go to sleep and wake up is in synchrony with your circadian rhythm.

- People who work evening and night shifts can suffer significant sleep deprivation until their bodies adjust to the new
pattern.

- Changing time zones can also disrupt sleep awake cycles and can thus be troublesome for people who travel frequently.
- Hospitalization can also interfere with the circadian rhythm, due to noises, lights, waking the patient for vital signs or
mediations, altered bedtime rituals, absence or presence of family members, and increased anxiety.

REGULATING SLEEP
- Sleep is controlled by the lower part of the brain that produces sleep by actively inhibiting wakefulness.
- Major factor in regulating sleep is the amount of light received through the eyes.
- Increasing light signals the hypothalamus to induce gradual arousal from sleep.

RETICULAR ACTIVATING SYSTEM (RAS)

- Reticular Formation - is responsible for maintaining wakefulness, by being activated by stimuli from the cerebral cortex.
- Neurotransmitters associated with excitatory and inhibitory sleep mechanisms include catecholamines, acetylcholine, serotonin, histamine,
and prostaglandins.
- Electroencephalogram (EEG) - is used to record the electrical activity of the neurons in the brain.
- Electrical impulses are transmitted from the brain through electrodes attached to the scalp.
- Alpha Waves - are high frequency, medium amplitude, irregular waves. These occur in the drowsy stage.

- Beta Waves - are high frequency, low amplitude, irregular waves. These occur during periods of wakefulness.

- Spindles or K Complexes - are peaked, irregular waveforms that occur in the earlier phases of non rapid eye movement
sleep

- Delta Waves - are low frequency, high amplitude, regular waves common in deep sleep.

- While the person is awake brain waves are very rapid, irregular, and low in amplitude, mostly alpha and beta waves.
- When a person is relaxed without intense stimulation of the senses the EEG records mostly alpha activity.
- During sleep, alpha waves disappear and are replaced by slower higher amplitude delta waves.

WHAT ARE THE STAGES OF SLEEP

- Key Point: there are two distinct types of sleep, Non Rapid Eye Movement (NREM) and Rapid Eye Movement (REM). the body moves back and forth
between them during the sleep cycle.

NREM SLEEP
- Non Rapid Eye Movement (NREM) - is when sleep is generally in the restful phase in which physiological function is slow.
- Deep or slow wave sleep characterized by the presence of delta waves.
- Cortisol is lowest during this phase
- NREM is divided into three stages, each deeper than the one preceding it.
- During NREM sleep muscles relax; body temperature lowers; Heart Rate, respirations, and blood pressure decrease.
- THis phase is thought to be important for memory consolidation; this is when information or skills move into long term memory.

REM SLEEP
- Rapid Eye Movement (REM) - sleep the brain becomes highly active and the brain waves resemble those of a person who is fully awake. Rapid Eye
movement occurs which can often be detected even though the person's eyelids are closed.
- More spontaneous awakenings occur during the REM stage than any other
- More dreams occur during REM sleep
- REM sleep is essential for mental and emotional Restoration
- Loss of REM sleep impairs memory and learning
- REM Rebound occurs when a person is deprived of REM sleep for several nights, resulting in greater amounts of time in REM sleep on
successive nights.
SLEEP CYCLES
- Key Point: Cycling between REM and NREM sleep produces restorative rest.
 - Four Stages of Sleep
- Three NREM stages
- The REM stage
- The NREM / REM sleep cycle repeats four to six times throughout the night, depending on the total amount of time spent sleeping.
- Each cycle lasts on average 90 to 100 minutes.
- The first REM period may last only about 20 minutes, each cycle, the REM period lengthens until, in the last cycle of a typical 8 hour sleep
period REM may last 60 minutes.

FACTORS THAT AFFECT SLEEP

AGE
TODDLERS & PRESCHOOLERS
- Have trouble falling asleep, frequent awakenings, nightmares and heavy snoring.
- Difficulty “Winding Down” after hectic activities in the late afternoon and early evening hours.

SCHOOL AGE CHILDREN & ADOLESCENTS

- They may suffer sleep disturbances related to stress, excitement, or social concerns, such as anticipating a school event or sports competition.
- Normal shifts in circadian rhythms that occur with puberty
- Increased demands at school, or staying up late to complete assignments
- Evening use of electronic device or sleep with smartphones near their bed
- The light produced by devices disrupts circadian rhythms and suppresses naturally occurring melatonin which makes falling asleep difficult.
- Caffeine, Alcohol, Nicotine, or Drug Use.

COLLEGE STUDENTS
- College students may stay up all night to study for examinations or may experience difficulty falling asleep or staying asleep because of stress about
grades or future career choices.
- Preference for late night schedule, yet have schedules requiring them to attend an earlier class.

YOUNG ADULTS
- Drive themselves too hard to succeed, prompting late nights at work or sleep loss due to hectic travel schedule or work related stress
- Not obtain enough sleep because of social and personal entertainment
- Work an evening or night shift.

PARENTS OF YOUNG CHILDREN

- They often experience sleep interruptions. Parents of toddlers often wake to care for a child who is having a nightmare, is ill, or needs to use the
bathroom.

MIDDLE AGED ADULTS

- Work or family
- The need to care for a parent
- Marital discord
- Worry about children
- Financial problems

OLDER ADULTS
- Side effects of medications
- Underlying illnesses
- Depression
- Discomfort
- Nocturia
- Pain
- Declining levels of melatonin, which occur in the latter decades of life

LIFESTYLE FACTORS
PHYSICAL ACTIVITY
- If exercise occurs at least 2 hours before bedtime, exercise promotes sleep. Fatigue from a normal physically active day is thought to promote a restful
nights sleep.
- Sedentary lifestyle is a factor for sleep disorder.

DIET
- A meal high in saturated fat near bedtime may interfere with sleep.
- Dietary L tryptophan and adenine are essential amino acids found in milk cheese, and animal products that may help to induce sleep by converting into
serotonin
- Carbohydrates seem to promote relaxation through their effects on brian serotonin levels. In general, station induces sleep, whereas many people,
especially infants and children, have difficulty falling asleep when they are hungry.
NICOTINE & CAFFEINE
- Nicotine
- Smokers tend to have more difficulty falling asleep and are more easily roused than nonsmokers.
- People who stop smoking often experience temporary sleep disturbances during the withdrawal period.

- Caffeine
- Blocks adenosine and thereby inhibits sleep.
- Individuals vary greatly in their sensitivity to caffeine.

ALCOHOL
- Disrupts REM and SWS and may cause spontaneous awakenings with difficulty returning to sleep.
- Vivid dreams in REM in some people, heavy alcohol consumption can prompt dreams that can lead to awakening during REM Sleep.
- Since alcohol is a diuretic, it can induce nocturia.

ILLNESS
- Disease symptoms like fever, pain, nausea and respiratory conditions can interfere with sleep.
- Specific disease conditions altering the quality of sleep include allergies, hyperthyroidism, and parkinson disease.
- Anxiety increases gastric secretions, intestinal motility, heart rate,and respirations all can contribute to a restless night.
- Depression may be associated either with too much sleep or with difficulty sleeping.
- Fear of the unknown outcome of an illness and role change associated with hospitalization can cause anxiety and interfere with falling or staying asleep.

ENVIRONMENTAL FACTORS
- Noise
- Noise can also inhibit sleep, but a person can become habituated to noise over time and be less affected by it.
- Some people routinely fall asleep to music or while listening to radio or television
- Loud noises may be needed to awaken a person in NREM stage III and REM sleep
- Equipment noise, the muffled sounds of a busy medical surgical unit, or the labored breathing or snoring of a roommate can
interfere with the patient's ability to sleep.

- Light
- When people who are accustomed to sleeping in a dark room are hospitalized, they may have trouble falling asleep because of light outside
their window or filtering into the room from the hallway.
- Light can be therapeutic for patients suffering from sleep problems.

COMMON SLEEP DISORDERS

- Dyssomnias - sleep disorders characterized by insomnia or excessive sleepiness.
- They include insomnia, sleep wake schedule disorders, sleep apnea, restless legs syndrome, hypersomnia, and narcolepsy.

- Parasomnias - patterns of waking behavior that appear during sleep.

INSOMNIA
- Insomnia - is defined as the predominant complaint of dissatisfaction with sleep quantity, associated with the inability to fall asleep, remain asleep, or
go back to sleep.
- The sleep disturbances cause significant distress or impairments in social, occupational, academic, behavioral, and other important areas of
functioning.

- True insomnia occurs at least three nights per week and is present for 3 months or longer, even when there is ample opportunity for sleep.

- Sleep difficulty may be transient / short term or chronic.

- People with sleep difficulty usually report an insufficient quantity and quality of sleep and wake without feeling refreshed, even
though they are often observed to sleep more than they perceive that they do.

INCIDENCE
- Key Point: insomnia is the most common sleep disorder.
- It is more prevalent in women and in older adults
- It is more common in Shift Workers

ETIOLOGIES
- Illness, depression, anxiety disorders, acute stress, substance abuse
- Side Effect of medications
- Poor Sleep Hygiene

SYMPTOMS
- Daytime consequences of insomnia include symptoms of excessive daytime sleepiness, poor concentration, fatigue, lethargy, and irritability.
- Insomnia can also create an increased risk for depression, anxiety, and possibly cardiovascular disorders
- Insomnia may be the presenting symptom of other primary sleep disorders, such as restless legs syndrome.
TREATMENT
- The use of medications to induce sleep is controversial because some types of medications can become habit forming.
- Sedative hypnotic treatment is justified in short - term insomnia to avoid the negative effects of insomnia on mood and performance.
- Short term aggressive treatment may prevent the development of chronic insomnia.

SLEEP WAKE SCHEDULE DISORDERS

- Abnormalities in sleep wake schedules may be caused by rapid time zone changes, shift work, or change in total sleep time from day to day.
- Symptomes include decreased vigilance, decreased ability to perform psychomotor tasks, and short sleep episodes that the person is not aware of.

RESTLESS LEG SYNDROME (RLS)

- Restless Legs Syndrome - is a disorder of the central nervous system characterized by a strong and often overwhelming urge to move the legs while
resting or before sleep onset.

INCIDENCE
- Hereditary
- It Tends to occur in women more often than men.
- Common in older adults, although children and young adults also experience this condition.
- Are sometimes associated with low levels of iron and stroke.
- Associated with the use of certain antidepressants

SYMPTOMS
- Unpleasant creeping, crawling, itching, or tingling sensations in the legs are relieved only by moving the legs, which prevents the person from relaxing
and falling asleep.

MANAGEMENT
- Decrease alcohol and tobacco
- Avoid stimulants, such as caffeine
- Maintain a regular sleep pattern
- Follow a program of regular, moderate intensity aerobic and leg strengthening exercise
- Walking, Massaging, stretching, heat or cold compress, medication, vibration, and acupressure
- Apply a foot wrap with a pad that delivers vibration to the back of the leg and also puts pressure underneath the foot
- Dietary iron supplement
- Dopaminergic agents an dedication used to treat parkinson disease
- Anticonvulsants to control the creeping and crawling sensation in the legs
- Benzodiazepines can help individuals get more restful sleep but should be reserved as a last choice because of side effects.

SLEEP DEPRIVATION
- Sleep Deprivation - is a nursing diagnosis, it is not a sleep disorder but rather a human response.
- Feel drowsy during the day or a have a general feeling of malaise
- Having difficulty performing daily tasks
- Experience impaired cognitive processing, problem solving, and decision making
- Exhibit restlessness, perceptual disorders, slowed reaction time, irritability
- Exhibit somatic complaints
- Experience delusions, paranoia, and other psychotic behavior if sleep deprivation is severe and prolonged
- Have diminished body protection against infection

HYPERSOMNIA
- Hypersomnia - is excessive sleeping, especially in the daytime.
- Doze, nap, or fall asleep at times and in situations when they need or wish to be awake and alert.
- Hypersomnia and narcolepsy; disorders of the central nervous system, kidney, or liver; and metabolic disorders
- Hypersomnia can also be a symptom of depression.

SLEEP APNEA
- Sleep Apnea - is a common disorder with serious consequences, and is when a person stops breathing while sleeping and can increase the risk of
diabetes, high blood pressure, and cardiovascular disease.

NARCOLEPSY
- Narcolepsy - is a chronic disorder caused by the brain’s inability to regulate sleep wake cycles normally.
- The distinction between being asleep and being awake is blurred
- The person experiences a sudden, uncontrollable urge to sleep lasting from seconds to minutes, even though the person sleeps well at night.

PSEUDO NARCOLEPSY
- Pseudo Narcolepsy is a condition characterized by involuntary episodes of sleep, but the episodes are related to acute or chronic sleep deprivation.

DEFINING CHARACTERISTICS
- Sleepiness, slurred speech, slackening of the facial muscles, a feeling of impending weakness of the knees, paralysis, and hallucinations
- Impaired performance during microsleep episodes
- Sleep episodes that come on suddenly, even while the person is alert and active.
 - Awakening from episodes of unavoidable sleep feeling refreshed
- Cataplexy - a sudden loss of muscle tone usually triggered by an emotional event but almost all patients only have hypersomnia.
- Intolerance of irregular sleep wake patterns, such as shift work, and difficulty staying awake with passive activity.

PARASOMNIAS
SLEEP WALKING
- Sleepwalking or Somnambulism, occurs during stage III of NREM sleep, usually 1 to 2 hours after the person falls asleep.
- The sleeper leaves the bed and walks about, with little awareness of surroundings.
- They may perform what appear to be conscious motor activities but do not wake up.
- The person is not aware of sleepwalking and has no memory of the event of awakening.
- Children sleepwalk more often than adults do.

SLEEP TALKING
- Sleep Talking occurs during NREM sleep, just before the REM stage.
- Speech is often disorganized and hard to understand.

BRUXISM
- Bruxism is grinding and clenching of the teeth. It usually occurs during stage II NREM sleep.

NIGHT TERRORS
- Night terrors are sudden arousals in which the person is physically active, often hallucinatory, and expresses a strong emotion such as terror.
- Children experience night terrors more frequently and typically cry or scream in fear, thrash about, and resist all attempts by their parents to hold or
console them.
- The child appears to be fully awake, but they are not; in fact typically returns to sleep without awakening and in the morning has no memory of the event.

NOCTURNAL ENURESIS
- Nocturnal enuresis, or bedwetting, is nighttime incontinence past the stage at which toilet training has been well established.
- It has incorrectly been associated with dreaming; however, most incidents occur during NREM sleep, during the first third of the night when the child is
difficult to rouse.
- Key Point: Because most children outgrow enuresis, the best strategy is patience

INTERVENTIONS FOR SLEEP

CREATE A RESTFUL ENVIRONMENT
- Be sure the bed linens are tight on the bottom and loose on top to allow movement
- Keep linens clean, dry, and free of irritants
- Good body alignment also facilities
- Keep the room dark and quiet unless the patient prefers a light
- As much as possible, control the temperature of the room and provide good ventilation.

PROMOTE COMFORT
- Be sure to offer pain medications at their scheduled times, and before the patients sleep time.
- Pain, itching, nausea may all be deterrents to rest and sleep in an ill person.
NOTES ON LECTURE
- Biological clock is different for each person; some people go to bed early, others stay up all night.
- Sleep helps the brain commit new information to memory through a process called memory consolidation.

- Falling asleep while driving is responsible for at least 100,000 crashes, 71, 000 injuries, 1550 deaths each year in the United States.
- Young People in their teens and twenties, who are particularly susceptible to the effects of chronic sleep loss, are involved in more than half of the fall
asleep crashes on the nation's highways each year.

- Sleep loss may result in confusion, irritability, impatience, inability to concentrate, and moodiness.
- Sleep deprivation alters immune function including the activity of the body’s killer cells.

- The Reticular Activating System contains cells that maintain alert wake state. People start to fall asleep stimulation is reduced thoughts slow, visual,
auditory stimulation decreases activation of the RAS decreases
- The entire sleep cycle is 90 mins and we have 4 to 5 full cycles / night
- The five cycles have been identified based on brain activity and physiological characteristics
- Non REM Sleep
- Or Slow Wave Sleep because it is characterized by Delta Waves the parasympathetic (rest and digest) conserves energy,
slows HR, relaxes GI sphincters and becomes progressively more dominant during each stage of NREM.

- Stage 1: is about 5% of the total night's sleep. Stage of light sleep, the person feels drowsy, eyelids feel heavy and the
person falls asleep, mostly consisting of alpha waves.

- Stage 2: Light sleep although brain activity slows, T, HR, and BP drop.

- Stage 3 Muscles are very relaxed and snoring may occur, Deepest sleep, very difficult to arouse. Delta waves at highest
amplitude, slowest frequency and synchronized. Some dreaming occurs but not as vivid as in REM Sleep. Restorative
processes such as protein synthesis and cell division and repair of tissue occurs. Growth hormone is released for repair
and renewal of the brain and other cells. Young Adults spend 11% of sleep here.

- Older Adults have a longer first REM Sleep

- Sleep Apnea is the most common sleep disorder and is obstructive to blocking the airway.
- Avoid alcohol, smoking, and lose weight
- O2 Stats can be very low while sleeping
- CPAP could be prescribed to aid in O2 saturation while sleeping.
- Central Apnea is due to dysfunction of the brain's respiratory center.
- Bruxism is teeth grinding.

- Restless Leg Syndrome can be found more often in patients with peripheral neuropathy, chronic kidney disease, Parkinson’s Disease, Iron Deficiency,
Certain Medications, Pregnancy.

- The need for sleep does not decline with age but the ability to sleep for six to eight hours at one time may be reduced.
NURSING 103: CHAPTER 46 NOTES
HOLISM
- Holism - emphasizes the relationships among all living things.
- Holism was the dominant philosophy throughout early history, but it fell out of favor in the 17th century when Rene Descarttes and other
influential philosophers introduced the mind and body as separate.

- Key Point: Jan Christian Smuts reinvigorated the belief in holism by declaring that living entities are more than the sum of their parts.

- The Body is all of the various pieces and parts working separately and together and with the environment all affecting each other.
- The following are affected and are being affected by each other:
- Body Spirituality
- Emotions
- Culture
- Relationships
- Environment

HOLISTIC HEALTHCARE
- Conventional Biomedical Treatment - is the use of conventional medicine to eliminate a pathology and treat symptoms until they are gone.
- Allopathy is a term used to indicate medical practice that treats disease with remedies that counteract the effects of the disease.

- Holistic Approach - is the enhancing of the person’s resistance to the illness.

- Holism emphasizes the need to change lifestyle behaviors that increase vulnerability to illness.

- It is complete when the person has healed into their best state of wellness and understands why the illness occurred, and adapted to lifestyle
changes to it.

- Modality is a method of treating a disorder.

- Complementary Modality - is a a treatment that is used together with traditional medical care

- Alternative Modality - is used instead of traditional medical care.

- Integrative Healthcare - refers to coordinated care that encompasses all treatments and health practices a patient uses.

THE PLACEBO RESPONSE

- Placebo Response - occurs as a result of the patients expectation that a treatment will be effective.
- An expression of Mind Body Unity, the placebo response is a basic underlying principle of holistic care.
- The Stronger the belief in the treatment's efficacy, the stronger the placebo effect will be.

- Nocebo Effect - is the power of the mind to create bodily distress.

- Key Point: In holistic care, treatment outcomes are enhanced if the practitioner and the patient believe that the treatment will be effective and if the
practitioner establishes an empathic and supportive relationship with the patient. The ideal relationship is mutual and based on equality, with the patient
assuming an active role in the treatment plan.

- Holistic Healers believe that all healing is self healing, and the placebo response demonstrates this natural phenomenon.

SPIRITUALITY AND HOLISM

- Spirituality is the process of discovering meaning, purpose, and fulfillment in life.
- Spirituality has a lot of influence on health and individuals ability to heal.
- Absence of spirituality creates a sense of disconnection from one’s true source, a loss of meaning to one's life, and state of disease.
- Holistic perspective incorporates the realities of the human condition, disease, disability, misfortune, aging, pain, and death into the life
experience.
- Illness and Disease are viewed as opportunities for transformation and growth.
HOLISTIC HEALTH BELIEFS
- Each Person is Unique
- Each person is a whole in constant interaction with the environment. The Body, The Mind, and The Spirit must come together to achieve harmony and
healing.
- Disease is a result of multiple contributing Factors rather than one cause
- Factors essential to health are social support, health practices, family illness patterns, personality traits, culture, child rearing practices, and relatedness
to nature.
- Hope, Faith, and the will to live are important to maintaining health and recovering from illness.
- The patient's expectation that the treatment will be effective is part of the self healing process. A positive state of mind is necessary to bring harmony to
the body.
- Each person is interconnected to others, nature, and the world.
- Health is achieved when there is balance, integration and harmony in life.
- Healthcare resources are better used when they focus on health promotion and disease prevention.
- Illness is an opportunity for growth and has meaning within the context of the life experience.
- Illness occurs when there is a shift in an individual's balance in any dimension or with the environment.

HOLISTIC PATIENTS
- Holistic Patients can be Women, people with higher education and income levels, and people with two or more chronic conditions are more likely to use
Complementary Alternative Medicine.

- Non Hispanic whites use Complementary Alternative Medicine more often than do Hispanics and Non Hispanic Blacks and are more likely to report
Complementary Alternative Medicine use to their healthcare provider.

- Complementary Alternative Medicine is used least by those below the age of 18 and used most by Middle Adults.
- Many parents use Complementary Alternative Medicine for their children.
- Common Complementary Alternative Medicine include Yoga, T’ai Chi, Qigong and chiropractic or osteopathic manipulation.
- Despite the popularity of Complementary Alternative Medicine most parents do not tell the child's clinician about Complementary Alternative
Medicine use.

WHY DO PATIENTS USE COMPLEMENTARY ALTERNATIVE MEDICINE

- Complementary Alternative Medicine was legitimized by the National Center For Complementary and Integrative Health.
- Increasing cultural diversity of the population and exchange of information about therapies form different cultural traditions.
- Complementary Alternative Medicine is used because people find it more in harmony with their own beliefs, and philosophical orientation toward health
and life.

- The Following are Reasons people use Complementary Alternative Medicines:

- People use it when they are dissatisfied with the impersonal nature of traditional healthcare and wish for more personal attention.
- Wish to promote health and avoid illness.
- Fear Adverse effects from traditional medical treatments or prescription drugs.
- Complementary Alternative Medicine usually has low risk and free of serious side effects.
- Lack of access to medical practitioners, or insurance coverage.

HEALTH CONDITIONS THAT PROMPT COMPLEMENTARY ALTERNATIVE MEDICINE USE

- Pain
- Chronic pain is hard to treat with regular medical approaches
- Of the 20 conditions for which Complementary Alternative Medicine is used, nine are associated with chronic pain.

- Cancer
- More than 60% of patients with cancer use prayer, relaxation, meditation, and massage.

- Other
- Other conditions are anxiety, elevated cholesterol, common cold, headache, and insomnia.

- For Children
- Parents report using CAM for their children for pain, anxiety, and stress disorders, enuresis, encopresis, sleep disorders, autonomic nervous
system dysregulation, habitual disorders, attention and learning disorders, diabetes, and asthma.

HOLISTIC NURSING
- Holistic Nursing is a theory based, relationship centered solution to such problems facing contemporary nursing in healthcare.
- Florence Nightingale emphasized that touch and kindness along with the healing influences of fresh air, sunlight, warmth, quiet, and
cleanliness, contributed to putting patients in their best condition to heal.

- Martha Roger’s View

- The environmental energy field is in constant and meaningful interaction with the human energy field. Nurses exert influence on these energy
fields to affect change in health status.

- Margaret Newman’S View

- Identified disease as a disequilibrium, which stimulates the person toward growth and regaining wholeness.
- Holistic perspective, disease is an inevitable part of the human condition and is necessary and beneficial for growth adaptation and maturation.
 - Jean Watson’s View
- Theory of nursing identified caring as the primary focus of nursing.
- Described “Authentic Presencing” which facilitates the “Caring Moment” between nurse and the patient.

HOLISTIC CONCEPTS
- Meanings - or individual constructions that reflect a person’s values, belief system, expectations, and the unique way in which the person experiences
health and illness.

- Therapeutic Use of Self

- Holistic nursing expands the therapeutic use of self to include awareness of the effects of presence and intention on the healing process.
- The presence of the nurse is an integral part of the patient’s environment.

- Role Modeling
- Holistic nurses role models healthy behaviors for their patients.
- Holistic nurse understands that their own health must be balanced, and it is difficult to maintain the energy necessary to be a constructive
presence and an effective practitioner.

- Integrated Lifestyle and Practice

- Healthful nutrition, sleep, rest, and relaxation benefit your function as a healthcare provider,
- Support Network of like minded colleagues serves as a resource

HEALING MODALITIES ARE COMMONLY USED

ALTERNATIVE MEDICAL SYSTEMS

- Alternative Medical Systems predate the traditional Western Health System.

AYURVEDA
- Ayurveda - A healing system from ancient India, covers all aspects of health and wellness, core belief is that a sense of harmony with nature and our
inner being produces health.
- Ayurveda attributes health to balance between three life forces, or energies called Doshas:
- Creation (Kapha)
- Preservation (Pitta)
- Destruction (Vata)
- Imbalance between these energies leads to illness and disease.
TRADITIONAL CHINESE MEDICINE
- Chinese medicine is the oldest continuously practiced medicine in the world.

- Traditional Chinese Medicine - is based on the writing that originated between 200 BC and AD 200 and involves the following elements and energies:
- Energies - Must be balanced between Yin and Yang.
- Elements - the Five elements of Earth, Water, Wood, Fire, Air / Metal.

- If an imbalance between these occurs then illness and disease will result.
- Energy flowing in your body can be determined by checking three pulses on the wrist. Determining your Qi or Chi and Yin and Yang balance.
- LIfestyle modifications and herbal remedies accompanied with acupuncture and moxibustion can be prescribed to rebalance energies.

ACUPUNCTURE
- Acupuncture - is the penetration of the skin with thin metallic needles to stimulate anatomical structures of the body.
- Acupuncture is derived from Traditional Chinese Medicine
- Energy or Qi or Chi is believed to travel through the body along channels known as meridians.
- There are 72 Meridians in the body, points along these meridians known as Acupoints are centers of nerve and vascular tissue.
- Stimulation of these points restores the flow of Qi along the meridians.

- Many studies have found that acupuncture can help with certain conditions, such as back pain, knee pain, headaches, and osteoarthritis.

HOMEOPATHY
- Homeopathy - is a complete system of medical theory and practice that is based on the understanding of how the body heals itself and an acceptance
that all symptoms represent the body’s attempt to restore itself to health.
- It was developed in the 5th century by Hipporcates.

- Law of Similars - is that substance that would cause the patient’s symptoms in a healthy person is the substance that is most likely to produce a
curative response in the patient who already has the symptoms.

- Law of Minimum Dose - Belief that minute doses will stimulate the body’s defenses against the disease, limiting side effects by diluting them in water or
alcohol mixing by succussion.

- Single Remedy - this principle guides the homeopathic practitioner to select one remedy that encompasses the totality of the persons symptoms and
constitutional characteristics.

NATUROPATHY
- Naturopathic Medicine - is a system of healing based on the healing power of nature.
- Key Point: Health is the outcome of understanding nature and allowing the body to heal itself. Diseases and aging result form ignoring the
laws of nature.

- Support the ability of the body to heal itself through nutrition and lifestyle counseling, dietary supplements, medicinal plants, exercise, massage, and joint
manipulation.

MIND BODY INTERVENTIONS

- Key Point: Mind body therapies are based on awareness of the unity of the mind and body and on the ability of social, familial, and economic factors to
affect all aspects of health and illness.
- Interventions target the patient's mood and reaction to stress to enhance health.
- Illness is viewed as an opportunity for personal growth.

PRAYER
- Prayer - is a dialogue with a spiritual being.
- Prayer exists in all religions and all forms of spirituality and may take the form of recited prose, meditation, or personal requests.
- People may pray for themselves or for others.
- Studies have found that 35% to 45% of patients used prayer for health concerns.

MEDITATION
- Meditation - uses practices that help to quiet and focus the mind and induce relaxation.
- Concentration meditation focuses on the breath, a sound or an object.
- Mindfulness Meditation involves directing attention to thoughts, feelings, and sensations.

- Meditation can be practiced in a group or alone.

- Meditating for as little as 20 mins a day can have positive effects on health, people reported feeling calmer, more focused, and relaxed.
- Health benefits include lower blood pressure, metabolic changes that reduce the effects of stress.
- Research found meditation significantly reduced risk of mortality, myocardial infarction, and stroke in coronary heart disease.

IMAGERY
- Imagery - or visualization uses the imagination to create a desired event or scenario.
- Nurses can use imagery to enhance their own energy state and performance.
- Visualizing yourself providing good care can increase your confidence and reduce stress.
- Imagery has been used to successfully reduce pain, and improve surgical outcomes, increase healing of joints, and enhance system function.
HUMOR
- Reading and telling jokes, viewing funny movies, or appreciating humor can release tension and increase coping abilities.
- Laughter releases endorphins and relieves stress
- Laughter produces increases in pulse, respirations, muscle tension and oxygenation.

MUSIC THERAPY
- Music Therapy - is the evidence based use of music interventions within a therapeutic relationship to achieve individualized goals.
- It is relatively risk free, but does require a credentialed professional who has completed an approved music therapy program.
- Music therapy can be designed to promote wellness, release emotions, manage stress, relieve pain, improve communication, and promote
physical rehabilitation.
- It has been used to keep Alzheimer's patients calm and improve their memories, and it can also help depressed patients express their
feelings.

- Number of clinical trials have shown the benefit of music therapy for short term pain, other studies have shown mixed results.
- Hospice care patients were found to have had improved comfort, relaxation and pain control.
- Listening to music was found to reduce blood pressure and heart rate in patients receiving bronchoscopy.

YOGA
- Yoga - is a 5,000 year old traditional art, science, and philosophy with origins in ancient indian philosophy.

- Yoga is designed to integrate body, mind, and spirit.

- Yoga typically combines physical postures, breathing techniques, and meditation or relaxation.

- Key Point: The ultimate goal of yoga is to awaken the spiritual identity and to instill happiness.

- Yoga is useful for some types of chronic pain

- Yoga is used to increase flexibility, strength, body alignment, stamina, balance, and concentration.

- Yoga traditionally is part of a practice intended to regulate the life force through breathing, meditation, reading sacred scriptures, and participating in a
community of students who seek the teaching of yogi masters.

HYPNOSIS
- Hypnosis - is a trance like state characterized by relaxed brain waves, hypersuggestibility, and heightened imagination.

- A certified hypnotherapist may induce the state, or people can learn self hypnosis.
- Hypnosis and self hypnosis have been used to promote relaxation, weight loss, and smoking cessation and to suppress various symptoms.
- It has been used to modify pain in childbirth and as an adjunct to or in place of anesthesia for surgery.

- Myths of hypnosis have developed from the use of hypnosis for entertainment as a stage act. The following are true statements about hypnosis:
- You do not surrender your free will or lose your personality under hypnosis. It is a heightened state of concentration and focused attention.
- The hypnotherapist does not control you. You do hypnosis voluntarily for yourself. The hypnotherapist is merely a guide or facilitator.
- Under hypnosis, most people do not lose consciousness or have amnesia.
- You cannot be put under hypnosis against your will. Successful hypnosis depends on your willingness to experience it.

BIOFEEDBACK
- Biofeedback - is a technique by which some people can learn voluntary control over involuntary activities, such as heart rate.
- Biofeedback techniques use electronic instruments to measure body functions such as brain activity, blood pressure, muscle tension, heart
rate, skin temperature, and sweat gland activity.
- Visual Auditory cues provide information to the patient in the form of sound or light.
- Immediate feedback helps the person to become aware of and learn how to voluntarily control certain physiological responses, such as stress.

BIOLOGICALLY BASED THERAPIES

- Dietary Supplements - is a product that contains a dietary ingredient intended to supplement the diet.
- Dietary ingredients may be herbal or non herbal.
- Dietary supplements occur in many forms, such as tablets, capsules, softgels, gelcaps, liquids, or powders.

- Key Point: Be sure to include questions about dietary supplements in your assessments.

- The FDA regulates biologically based therapies and is developing guidelines for good manufacturing practices.

- Key Point: It is difficult to know what dosage you are obtaining from a product, and safety cannot always be guaranteed.
- Key Point: No biologically based therapy has been proved safe and effective for older adults in treating sleep problems, depression, and
anxiety.
- Fish Oil / Omega 3 is the most popular natural product used by Adults.

- Ingestion of dietary supplements sends more than 23,000 people to the emergency room in the United States each year.
- Children under the age of 5 account for 20% of those visits.
- Adults aged 20 to 34 make up the majority of those visits .
DIETARY THERAPIES
- DIetary Therapies - are used in traditional healthcare as well as with Contemporary Alternative Medicines.

- An ayurvedic medicine patient's pitta dosha might be represented by the element of fire and foods that are “cool: in nature" are recommended
to balance the patients “fiery” nature.

- In traditional Chinese medicine illness results when there is an excess of wind, cold, fire, summer heat, dampness, or [Link] that have
opposite qualities are used to counteract these excesses.

- Naturopathy stresses the importance of pure food, recommending generous servings of raw food to prevent disease and aging.

- Mainstream research has repeatedly demonstrated that as foods become more processed, the incidence of chronic disease has increased.

HERBAL PRODUCTS
- People have used herbal remedies since the beginning of time.
- Many prescription medications in use today are derived from herbs.
- Herbal products are often viewed as natural and therefore are sought out by people who wish to avoid exposure to chemicals.
- One study concluded that nearly one in five people in the United States reports using an herb for health promotion or to treat a health
condition.

- 10% of people used melatonin, 7.5% used echinacea, 6.4% used garlic, 6.4% used cranberry, 5.8% used ginseng, and 5.4% used ginkgo.

- Consumers state that their primary reason for using herbal supplements is to promote overall health and wellness.

- Lack of Standardization
- One risk is that when you buy a product, you do not know for sure what you are getting.
- The FDA regulates herbs as dietary supplements, the manufacturing standards are not as strict as are those for medications.
- Different products may contain different amounts of the active ingredient that may even contain harmful contaminants.
- Herbs may change based on soil and weather conditions in which they grow.

- Lack of a Formulary
- In some countries a health commision has reviewed the safety and efficacy of many herbs and created a monograph or formulary detailing
findings.
- The United States does not have a national formulary but the FDA has begun investigating how to study and regulate herbal products.

- Interaction with Other Medications

- Many herbs are known to interact with medications and to adversely affect some disease processes or lab results

- Toxicity
- Some herbal supplements can be toxic even without interaction with other drugs.
- Misidentification, contamination, and adulteration may contribute to this.

AROMATHERAPY
- Aromatherapy - is the use of essential oils, which are concentrated extracts of roots, leaves, or blossoms, to enhance physical and mental well being.
- Aromatherapy is known to relieve stress and have well proven antibacterial, antibiotic, and antiviral properties.
- Animal studies demonstrate the calming or energizing effects of essential oils and their effects on behavior and immune responses.
- Clinical trials of aromatherapy are mixed, a few early studies indicate it may improve symptoms of nausea or pain and lower blood pressure,
pulse, and respiratory rates in patients with cancer.

MANIPULATIVE & BODY BASE METHODS

CHIROPRACTIC
- Chiropractic - forces on the relationship between the structure and the function of the human body.
- Key Point: the premise of chiropractic is that disease is caused by irritation of the nervous system. A total of 31 pairs of spinal nerves branch
off the spinal cord to innervate all the organs in the body. Subluxation of the vertebrae impinges on these nerves and leads to disease.

- Adjustment - is the manipulation of body structures that realigns and improves nerve impulses.

MASSAGE
- Massage - is the manipulation of muscles and other soft tissues.
- It is one of the oldest forms of healing.
- Massage helps promote the following:
- Promoting muscle relaxation
- Increases lymphatic circulation, reducing inflammation.
- Breaking up scar tissue and adhesions
- Promoting blood flow through the muscles
- Enhancing parasympathetic nervous activity
- Promoting drainage of sinus fluids
- Swedish Massage
- Is used to induce relaxation and restore flexibility. It consists of five basic strokes:
- Effleurage, Petrissage, vibration, tapotement, and friction.
 - Sports Massage
- Is a form of Swedish massage that facilitates maximum physical performance, pressure, movement, and cross fiber massage in a vigorous
manner are used to warm up athletes before events, to relieve soreness after exertion and to help repair athletic injuries.

- Myofascial Release
- Restores balance, alignment, and mobility to the body by releasing tension in the soft connective fasciae through trigger point release,
strumming, and muscle stretching.
- Light pressure and stretching but not to the point of pain.

- Rolfing
- Also known as Structural integration is similar to myofascial release but is generally thought of as more intense.
- Deep tissue massage.
- Manipulates connective tissue to allow the body to align itself so it is vertical in the field of gravity.
- Rolfing considers the effect of structure and gravity on human function, and patients may need it.
- People get rolfed to relieve chronic pain, improve flexibility and posture, release emotional trauma, and strengthen the mind body connection.

- Shiatsu Massage - is a finger pressure method that balances the energy force in the body.
- Applies pressure to the specific points that lie along energy meridians that are used in acupuncture.

- Reflexology is a massage technique that applies pressure to the feet to promote unblocking a terminal nerve to improve function along that nerve
pathway.

OSTEOPATHY
- Osteopathy - is a hands on, whole body approach to medical care that emphasizes the role of the musculoskeletal system in health and disease.
- Osteopaths are licensed and granted the same privileges as Medical Doctors, they can also prescribe medicine and perform surgery.
- Osteopathic Manipulation - a method focused on normalizing joint function, eliminating strains, and facilitating the function of the primary
respiratory mechanisms.

ENERGY THERAPIES
- Energy Therapies - are widely used Complementary Alternative Medicines that involve energy fields.
- Biofield Techniques affect energy that surrounds and penetrates the body.
- Bioelectromagnetic therapies involve the use of electromagnetic fields for healing purposes.

THERAPEUTIC TOUCH
- Therapeutic Touch - a biofield therapy, uses hands on or near the body to provide comfort, pain relief, and healing.
- Key Point: the premise of Therapeutic touch is that humans consist of energy fields that penetrate the body and extend 5 to 15 cm beyond the
physical structure. In health, energy flows freely through the system in a blanched manner. But in illness or pain, the free flow of energy is
disrupted.
- Therapeutic Touch hands clear, energize, repattern and balance the energy field to produce a more healthful state.
- Therapeutic Touch is noninvasive and can be used as primary or adjunctive treatment in many settings, with clients of any age, and
for a variety of conditions.

- Therapeutic Touch has been found to reduce anxiety, reduce pain, accelerate healing, enhanced immune functioning, reduced agitation
among dementia patients, and enhanced well being.

T’AI CHI AND QIGONG

- There are many styles of T’ai Chi and Qigong
- Key Point: Chi cultivation involves relaxing the body, regulating or controlling breathing, and calming the mind. T’ai Chi and Qigong facilitate energy flow
through the meridian system so that qi can be strong and balanced to support health.

- T’ai Chi provides some of the benefits of low impact exercise as well as prevents falls by improving balance in older people.

- T’ai Chi is effective for maintaining bone density in postmenopausal women, for enhancing the immune system, for improving range of motion in people
with rheumatoid arthritis, and for reducing blood pressure.

REIKI
- Reiki - is a biofield energy therapy that originated in japan, it seeks to balance energy to enhance the body’s ability to heal itself.
- The patient draws the needed energy from the hands of the practitioner rather than the practitioner imparting energy.
- Reiki does not involve touch but the hands being positioned a few inches over the body.
- Reiki is administered to practitioners who have undergone an initiation process in which the Reiki master employs ancient sounds and
symbols to attune the nervous system to higher levels of energy.
- Reiki can be used for self care, promoting relaxation, stress reduction, symptom relief, and improving health and well being.

MAGNET THERAPY
- Magnet Therapy - is an energy therapy that uses the property of magnetism to treat a variety of human conditions.
- The most widely claimed effect is improvement in musculoskeletal pain for patients with injury or arthritis.
- Magnet therapy operates on the premise that the iron in hemoglobin is attracted to the magnet placed on the skin.
- Application of a magnet to an injured or fatigued area increases blood flow, which is supposed to aid in healing.
- Many magnet products are available without prescription and without the need to consult a healer.
- Studies on the efficacy of magnet therapy show mixed findings and do not firmly support a conclusion on pain relief.
NURSING 103: CHAPTER 13 NOTES
LOSS
- Loss can be defined as the undesired change or removal of a valued object, person, or situation.
-
CATEGORIES OF LOSS
- Actual Loss - includes the death of a loved one, theft, deterioration, destruction, and natural disaster.

- Perceived Loss - is internal; it is identified only by the person experiencing it.

- Example: a woman diagnosed with a sexually transmitted infection may perceive herself as having lost her purity.

- Physical Loss - includes injuries, removal of an organ, and loss of function.

- Psychological Losses - or perceived losses, commonly seen in the areas of sexuality, control, fairness, meaning, and trust and challenge our belief
system.

- Loss can be a mix of the categories

- Example: After removal of a prostate gland, a man may feel both the physical and psychological loss of sexuality.

- External Losses - are actual losses of objects that are important to the person because of their cost or sentimental value
- These losses can be brought about by theft, destruction or disasters such as floods and fire.

- Internal Loss - is another term for perceived or psychological loss.

- Loss of Aspects of Self

- These losses include physical losses such as body organs, limbs, body functions or disfigurement.
- Psychological and Perceived losses in this category include aspects of one’s personality, developmental change, loss of hopes and dreams,
loss of faith.

- Environmental Loss - involves a change in the familiar, even if the change is perceived as positive.

- Loss of Significant Relationships - includes, but is not limited to actual loss of spouses, siblings, family members, or significant others through death,
divorce or separation.

GRIEF
- Whenever there is significant loss there is grieving
- Grieving is positive and essential to psychological healing after a loss.
- Key Point: The intensity of the grief depends on the meaning the person attaches to the loss.

- Grief - is the physical, psychological, and spiritual responses to loss.

- Mourning - consists of actions associated with grief

- These processes are normal and natural responses to a loss.

- Bereavement - is the period of mourning and adjustment after a loss.

- Emancipation - is the feeling of freedom, may be accompanied by guilt.

- Key Point - although each person may express grief differently, some aspects of grief are shared by almost everyone.
THEORETICAL FOUNDATIONS OF GRIEF
- Grief is presented to occur in stages and that people do not move from one stage to the nex but grieving is a fluid, ongoing process.

THREE STAGES OF GRIEF

- Georg Engel (1961)
- Uncomplicated grief is universal, has a clear onset and predictable course, and does not require treatment.

1. Shock & Disbelief -

- Initial phase
- The sufferer denies the loss in an attempt to protect against the shock of reality.

2. Awareness of Loss
- Painful feelings of sadness, guilt, shame, helplessness, loss, and emptiness.
- Loss of interest in activities
- Impaired work performance.

3. Restitution & Recovery

- Final phase, prolonged and gradual,
- Carries on the work of mourning and overcomes the trauma of the loss.
- State of health and well being is reestablished.

PHASES OF GRIEF
- John Bowlby (1982)
- Attachment theory describes the reaction to strong emotional bonds that have been developed. The individual must work through each process to avoid
complicated Grief. Grief is a mature way of dealing with loss of attachment.
1. Shock & Numbness
- Initial Stage
- Disorientation
- Feelings of Helplessness

2. Yearning & Searching

- The grieving person yearns to be reconnected with the deceased and searches for connections.

3. Disorganization & Despair

- Permanence of the loss now real
- Feelings of pain
- Emotions of grief to the fullest
- Feels there is no hope of reconnection

4. Reorganization
- Adjusting to life without the deceased
- Developing new coping skills.

THERESA RANDO'S THEORY OF GRIEF

- Identified the three Processes of Grieving and six tasks associated with overcoming grief.
- Three Processes of Grieving
1. Avoidance
- Shock, Disbelief, Denial, Anger, Bargaining

2. Confrontation
- Begins to face the loss
- A very emotional and upsetting time when grief is felt most acutely.

3. Accommodation
- Begins to live with the loss
- Feels better
- Resumes some routine activities
- Six Tasks of Overcoming Grief (Six R’s)
1. Recognizing the loss
2. Reacting to the Separation
3. Recollecting memories of the Deceased
4. Relinquishing the old attachment
5. Readjusting to the new environment
6. Reinvesting in self.
FOUR TASKS OF GRIEVING
- William Worden (2002)
- Accepting the Reality of Loss
- Realizing that the loved one or object is gone.
- In the hours and days after a significant loss, the grieving person typically feels numb and unable to accept the fact of the
loss.
- The task of realizing the loved one or object is gone may take several days or in the case of sudden death weeks.
- Working THrough the Pain & Grief
- Feelings and Emotions that surface are intense and can change rapidly.
- Feels “Out of Control”
- May say they feel as if they are “going crazy”
- Usually the longest phase because none of us like to be in pain, we become an expert at finding ways to not feel it, and
caring people do not like to see their loved ones in pain, so they make attempts to remove the pain rather than letting the
person experience it, prolonging the process.

- Adjusting to the Environment in Which the Deceased is Missing

- Adjusting to the environment without the deceased.
- This may mean performing alone activities and tasks
- Taking on roles and responsibilities the deceased previously held
- Such experiences can be extremely sad, frustrating, and challenging, or very rewarding.
- Once the person has established the new pattern, they typically feel satisfaction and increased self esteem.
- Emotionally Relocating the Deceased and Moving on with Life
- Investing Emotional Energy
- Initially all energy is focused on the deceased thinking about the person, talking about them, reliving memories.
- Concentration is difficult, so it is hard to engage in activities such as reading or that require focus.
- When the person's energy begins to flow toward others or to different or former interests.

FIVE STAGES OF GRIEVING

- Elisabeth Kubler - Ross (1969)
- Individuals may not experience every stage or go through the stages in a linear order. In addition, individuals may experience two or more stages
simultaneously.
- Denial
- “Not Me” , “This Can't be Happening” ,“ I Don't Believe It”
- The person is usually in a state of shock.
- Denial is not necessarily negative; it gives the person a chance to prepare psychologically for accepting the news.

- Anger
- “Why Me” , “Why is this Happening”
- Anger can be obvious or subtle.
- Anger is the person's response to the feeling that the situation is unfair
- The person may take their anger out on people who are “safe” or from whom there will be no reprisals.

- Bargaining
- “If only i can live until…” “Yes Me, but…”
- Usually this takes the form of a bargain with a higher power, in which the person asks to live to see a birth, graduation, wedding, or
other life event.

- Depression
- A withdrawn sadness, not to be confused with clinical depression
- This is a response to the current loss as well as to any accumulated and or future losses.

- Acceptance
- Not necessarily wanting death or the loss but coming to terms with it and ceasing to fight it.
- The person may seem almost devoid of feelings.

DUAL PROCESS MODEL

- Margaret Stroebe & Hank Schut (1999)
- Mourning is cyclical. People oscillate between two dimensions in bereavement.
- Loss Oriented Response
- Focuses on grief work
- Concentrates on appraising and processing the loss; searches for meaning
- Experience pain.
- Restoration - Oriented Response
- Focuses on dealing with the consequences of the loss
- Establishes new routines and takes on new roles
- Reorients to the world without the deceased person.
CONTINUING BOND MODEL
- Dennis Klass, PHylilis R. Silverman , Steven L. Nickman (1996)
- Bereavement
- The focus should be on finding new ways to relate to the deceased, not on obtaining closure.
- The griever maintains a continuing bond with the deceased.
- Negotiate and Re - Negotiate
- The meaning of the loss is negotiated and negotiated over time.
- The emphasis is not on achieving closure or forgetting
- The emphasis is on establishing therapeutic expressions of continuing bonds to adapt to the loss.

MEANING MAKING MODEL OF GRIEF / BEREAVEMENT

- Grieving is a process of meaning reconstruction
- A positive adaptation to loss is the ability to find meaning in the loss
- The unsuccessful struggle to find meaning can result in complicated forms of grief.

FACTORS AFFECTING GRIEF

- Significance of the Loss
- The meaning the person has attached to the person or object lost will be different for each person
- The greater the amount of attachment the more difficult the grief will be.
- Support System
- People with strong emotional and psychosocial support typically have less complicated grief.
- Unresolved Conflict
- Prolonged or Dysfunctional grief can occur with unresolved conflict.
- A conflict left unresolved may cause prolonged grief.
- Circumstances of the Loss
- The manner and circumstances of the death can leave the bereaved feeling guilty, responsible, or unprepared.
- Violent deaths can result in prolonged or complicated grief.
- Previous or Multiple Losses
- A person who has sustained several losses in a short period of time may experience complicated grief.
- Spiritual Cultural Beliefs and Practices
- Spirituality and Religious beliefs can help or hinder the grieving process
- One person may believe the deceased is in a place of contentment and happiness while another may believe that the deceased person will
be reborn into another form, yet another may believe that death is final and there is no afterlife.
- Timeliness of the Death
- The death of a child or a young person is almost universally more difficult to accept than the death of an older person.
- Loss of the person there is a sense of unfairness because of the loss of potential of what a child might have become or achieved.

DEVELOPMENTAL STAGES & GRIEF

CHILDHOOD
- Preschool children tend to believe death is temporary and reversible as with cartoon characters that “Die: and then “Come to life again”
- During early childhood children begin to understand that death is permanent, but they believe that it will never happen to them or anyone they know.
- Young children believe they are the cause of what happens around them. Referred to as Magical Thinking, this may cause them to feel guilt when there
is death of someone close to them.
- Other responses include regressing to previous stages of development: “Baby talk”, demanding food and attention, incontinence.
- A Child in the first few weeks after death may or may not display sadness or may pretend that the person is still alive; these are normal reactions.

ADOLESCENCE
- Adolescents are struggling to learn who they are as a person as they break away from parental control. The loss of a parent during this time may create
a sense of guilt and unfinished business.
- Bereaved teen also faces psychological, physiological, social, and academic pressures.
- Although teens may look mature, they lack emotional maturity but are often expected to “Grow Up” and support a surviving parent or younger siblings.
- Research shows that bereaved youths who have lost a parent or sibling experience a wide range of unhealthy symptoms and behaviors.

ADULTHOOD
- Cognitively able to understand the nature of death and have usually experienced other types of loss.
- Over time they perceive loss as a normal part of living.

OLDER ADULTHOOD
- Older Adults are especially difficult due to the cumulative effects of the many losses that they experience.
- Most deaths occur among older adults, losing their friends and siblings in rapid succession, in addition to physical and functional loss and loss of
independence.
- Loss of a child can create significant and sometimes irreparable mental and physical outcomes, accelerated disabilities, and loss of the ability to function
independently.
TYPES OF GRIEF
- Uncomplicated Grief - is the natural response to a loss of a person or object.
- The bereaved person may experience a range of feelings, behaviors, and cognition related to the loss.
- Emotions are initially intense but gradually diminish over time.
- Dysfunctional (Complicated Grief)
- Also known as prolonged grief, this is characterized by intensity of emotion and length of time.
- The person's responses are maladaptive, dysfunctional, unusually prolonged, or overwhelming.
- Chronic Grief - begins as normal grief but continues long term, with little resolution feelings and inability to rejoin normal life.
- Masked Grief - occurs when the person is grieving but expressing the grief through other types of behavior.
- Delayed Grief - is grief that is put off until a later time.

- Disenfranchised Grief - this is experienced in connection with a loss that is not socially supported or acknowledged by the usual rites or ceremonies.
- The bereaved person lacks the familial or communal support that is helpful in grieving.
- Anticipatory Grief - this type of grief is experienced before a loss occurs.
- Potential negative outcomes of anticipatory grief are that the survivor may detach from a dying person too early in the dying process, leaving
the dying person without emotional support, or it may prolong the grief of the survivor

DEATH & DYING

- Higher Brain Death - defines death as the irreversible cessation of all “higher” brain functions.
- A functioning brain stem could maintain both respiratory and cardiac activity, although the person does not make purposive responses to
external stimuli, cephalic reflexes are absent, and the electroencephalogram shows no activity.

- Uniform Law Commission

- Redefined death broadly as the irreversible cessation of all functioning of the brain including the brainstem as determined by reasonable
medical standards.

- Uniform Determination of Death Act

- Was adopted in 1981 to further clarify and expand the previous definition to include the irreversible cessation of circulation and respiratory
functions based on acceptable medical standards.

COMA & PERSISTENT VEGETATIVE STATE

- Coma - is a prolonged, deep state of unconsciousness lasting days or even years.
- The patient cannot be aroused and may not have decreased brainstem reflexes.
- Persistent Vegetative State (PVS) - the loss of higher cerebral functions, and the person does not purposefully respond to stimuli, is unaware of the
environment, and has no cognition or affective mental functions.

PHYSIOLOGICAL STAGES OF DYING

- 1 - 3 Months Before Death
- The dying person begins to withdraw from the world and people.
- Sleep increases it becomes difficult for the body to digest food, especially meats; and appetite and food intake decrease.
- Liquids are preferred.
- Anorexia and the resulting ketosis may be protective, as they can diminish pain and increase the person's sense of well being.

- 1 - 2 Weeks Before Death

- A host of physical changes indicates the body is beginning to los the ability to maintain itself.
- Cardiovascular deterioration brings reduced blood pressure, changes in pulse and skin color, and extreme pallor of the extremities.
- Temperature fluctuates, and perspiration increases.
- Respiratory rate may increase or decrease during sleep

- Days to Hours Before Death

- Often a surge of energy brings mental clarity and a desire to eat and talk with family members.
- Patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume.
- Tissues of the tongue and soft palate sag, and the gag reflex declines, so secretions accumulate in the oropharynx or bronchi.
- Respirations - breathing may be shallow, rapid, or irregular; periods of apnea may lengthen to 10 to 30 seconds before breathing
resumes.
- Cheyne - Stokes Respirations - this is a cyclic pattern consisting of a 10 to 60 second period of apnea and then a
gradual increase in depth and rate of respirations.

- Peripheral Circulation - decreases, and the person perspires and feels “clammy.”
- Blood pressure decreases; pulse may be hard to detect
- Extremities become cool and mottled; the underside of the body may be much darker.
- Decreased circulation also results in reduced kidney function and decreased urinary output.

- Elimination - as peristalsis slows, the patient may retain feces. Urine output decreases, and urine often becomes more
concentrated and foul smelling.

- Muscles - throughout the body relax, causing the face to “droop”.

- Vision - blurs; the eyes may be open or partially open but unseeing.
 - Cognition - in the final hours of life, many patients become restless and agitated. This response may be caused by medications,
liver failure, cerebral hypoxia, renal failure, stool impaction, distended bladder, increased pain, unresolved emotional or spiritual
issues.

PSYCHOLOGICAL STAGES OF DYING

- May not go through every stage
- May not go through the stages in a linear fashion, but rather in random order
- Does not necessarily complete one stage and move on to the next.
- May experience two or three stages simultaneously.

- Key Point: Remember that it is not the nurses responsibility to move people to the next stage so that dying patients accept death. It is our responsibility
to accept and support people where they are and help them to verbalize their feelings. We need to understand patients, not change them.

END OF LIFE CARE

- The patient has a fatal condition
- Death is likely with the next exacerbation of disease
- The patient acknowledges the seriousness of the situation.
- Making a holistic assessment of patients and families
- Acknowledging diversity in patients beliefs and customs
- Promoting the provision of comfort care to the patient by addressing symptoms
- Evaluating the impact of traditional, complementary, and technological therapies on patients, families, and established outcomes.
- Incorporating essential communication strategies that meet spiritual and cultural needs
- Applying legal and ethical principles to end of life care
- Demonstrating respect for the patients views and wishes during end of life care.
- Assessing patient, family, colleagues, and one's own success in coping with suffering grief, loss, and bereavement at the end of life.
- Recognizing one's own attitudes, feelings, values, and expectations about death and dying.
- Providing quality postmortem care.

PALLIATIVE CARE
- Palliative Care - is actually aggressively planned comfort care. It addresses end of life care concerns that include supporting families and caregivers,
promoting continuity of care, ensuring respect for persons, addressing emotional and spiritual concerns, managing symptoms and ensuring informed
decision making.
- When patients reach a stage in which there is no longer a cure possible, or when they refuse further treatment, they may be eligible to receive “comfort
care.”

HOSPICE CARE
- Hospice care focuses on holistic care of the patients who are dying or debilitated and not expected to improve.

- Hospice Care is based on two key premises

- The quality of life is as important as the length of life.
- Those who are terminally ill are allowed to face death with dignity and surrounded by the comfort of their homes and families.

- The purposes of admitting a patient to hospice are to

- Provide a family with some respite for a period of time
- Stabilize a patient who requires symptom management.
- Care for a patient who is in the end stage of a disease and needs a level of expert care that family members cannot provide at home.

- An interprofessional team plans holistic care with the patient and family
- Family members are encouraged to be active in the team to the extent they are able
- Nursing support is available 24 hours a day, and families are taught what to expect as the disease progresses. As the patient nears death
hospice workers remain as long as necessary.
- After the patient dies, there is follow up bereavement care for the families.

ADVANCE DIRECTIVES
- Advanced Directive - is a group of instructions (Written or Oral) stating a person’s wishes regarding their healthcare if they are incapacitated or unable
to make that decision.
- Only a durable power of attorney for healthcare can make healthcare decisions for the patient

- Patient Self - Determination Act (PSDA) - passed by congress in 1990, requires that all healthcare providers who receive medicare funds must
educate staff and patients, provide patients with information on their rights to accept and refuse treatment, and provide an opportunity for all patients to
complete an advance directive.

- Living Will - is a document that provides specific instructions about the kinds of healthcare the person would wish or would wish not to have in
particular situations.

- Health Care Proxy - identifies another person to make decisions for the individual regarding healthcare choices when an individual is unable
to do so based on circumstances.
- The individual should provide specific instructions about their desires regarding hydration, feeding tubes, medication, resuscitation,
and mechanical ventilation.
 - Key Point: Some people fear that once an advance directive is signed, no further care will be provided. Explain to families and patients that
this is not true; instead, the directive is intended to make sure they will get however much or little care they wish.

PRESCRIPTIONS FOR DNR / DNAR

- DNR prescription - is written by a provider and means do not resuscitate the patient in the event of cardiac or respiratory failure.
- Key Point: You must know the terminology used by your healthcare organization and pay careful attention to agency policies and advance
directives so you are prepared if the patient suffers a cardiopulmonary arrest.

- You should explain to patients and families what CPR involves and their available options.
- Key Point: providers must clearly specify any limitations to a full code, and the prescription should align with agency policy.

MEDICAL AID IN DYING (MAID)

- MAID permits a competent adult with a terminal illness to self administer oral or enteral medications that may hasten death.
- Nurses must respect the patient's right to self determination in end of life decisions and remain non judgemental and supportive.
- Key Point: In keeping with the code of ethics, nurses are ethically prohibited from administering MAID medications but must be knowledgeable of the
arguments for and against MAID and of their own personal value system.

PALLIATIVE SEDATION
- Palliative Sedation - is the controlled and monitored use of sedatives and nonopioid medications to induce unconsciousness to relieve suffering from
refractory and unendurable symptoms.

ASSISTED SUICIDE
- Assisted Suicide - means making available that which is needed for the patient to end their life.
- The patient is physically capable of ending their own life, has expressed the intention to do so, and has turned to the healthcare provider to
supply the means.

- Physician assisted suicide is legal in a few states ANA opposes assisted suicide because it is not consistent with the commitments of the
nursing profession and violates public trust.

EUTHANASIA
- Euthanasia - refers to the deliberate ending of the life of someone suffering from a terminal or incurable illness.
- ANA opposes euthanasia for it violates the commitments of the profession and public trust.

- Active Euthanasia - is the result of a direct action. It can be voluntary (patient consents) or involuntary (patient refuses) or non - voluntary (patient is
unable to consent or someone else makes the decision and the patient is unaware of it).
- Example: giving an overdose of medication.

- Passive Euthanasia - occurs as a result of a lack of action.

- Example: Withholding medications or food necessary to sustain life.

AUTOPSY
- Autopsy - is a medical examination of the body to determine the cause of death.
- Autopsies provide relevant data about disease processes and causes.
- The pathologist performs a detailed internal and external evaluation of the body, removes body organs, and extracts sample tissues.
- The autopsy requires signed permission from next of kin except when it is required by law in the case of suspicious or unwitnessed death.

ORGAN DONATION
- Uniform Anatomical Gift Act - provides guidance on tissue, eye, and organ donation.
- The act was amended to add language to prevent others from overriding an individual's prior decision regarding organ donation.

- Key Point: Conflict between a potential organ donors advance directives and measures to ensure the viability of the donors organs must be
resolved as soon as possible in this order:
1. The donor
2. The Surrogate decision maker
3. Another person as authorized under state law

- As a rule general donors must be at least 18 years of age or an emancipated minor

- Next of kin can donate organs when a person dies, unless an objection is known.
- Relatives cannot revoke a person’s donation, even after death
- The person making the gift can amend or revoke it at any time.

INTERVENTIONS FOR GRIEF

- Key Point: Your ability to help someone who is grieving or dying is largely determined by your attitude. Full spectrum nurses combine their psychomotor
and thinking skills with compassion in ministering to those who are suffering.

THERAPEUTIC COMMUNICATION
- Therapeutic Communication - is critical to building a trusting relationship with the dying or grieving patient and their significant others.
- It is most important to listen to the dying patient and to be alert for and respond to nonverbal cues.
- Encourage patients and family members to express their feelings and reassure them that their feelings are normal and not “wrong.”
FACILITATING GRIEF WORK
EXPRESSING FEELINGS
- Encourage questions, and respond to them within a reasonable time.
- Sit beside the head of the bed; do not appear rushed.
- When you observe the patient or family member expressing feelings, either verbally or nonverbally, encourage them to continue.
- Expect and accept a wide range of feelings, including anger, fear, and loneliness.
- Ask “How would you like me to help?” “What do you need?”
- Be sure that everyone on the healthcare team understands and follows the care plan
- Ask yourself what you would do if this were your family member
- Do not compare another person's loss with your own experience.

RECALLING MEMORIES
- To encourage recall is to go through photos with them and ask questions about the people in the pictures.
- Look for objects of sentiment in the environment and ask the dying or bereaved person to share their significance.

FINDING MEANING
- Help the patient or family find meaning in their lives or in their past.
- Facilitating life review is one technique to help the patient recognize the unique contributions this person has made on family, friends, and society.

BIBLIOTHERAPY
- Bibliotherapy - is a counseling technique used when grief therapy is indicated.
- Utilizes guided reading of self help literature or fiction to increase client awareness and understanding and promote healing.
- Poems, novels, and essays can help produce new insights, either as the client retells the story or is guided to discuss their feelings and
thoughts about the characters in the story.

CARING FOR THE DYING PERSON

- To effectively care for terminally ill patients, you must meet their physiological, psychological, social, sexual, and spiritual needs.
- Most hospitals and hospice facilities have an interprofessional team to provide holistic care to dying patients and their families.

MEETING PHYSIOLOGICAL NEEDS

- Active dying usually occurs over a period of 10 to 14 days.
- In the “Final Hours” , the last 4 to 48 hours of life, most patients need skilled care around the clock as body systems fail.
- Older adults top priority is comfort at the end of life
- 10% of the very old experienced unconsciousness during the final stage fo dying, thus attention to the most common symptoms of pain and distress
must be addressed

MEETING PSYCHOLOGICAL NEEDS

- The primary provider is usually responsible for deciding what and how much to tell the person.
- Most patients want to know their prognosis as soon as possible so that they can put personal affairs in order, share their feelings with family and come to
terms with life and death.

ADDRESSING SPIRITUAL NEEDS

- When a person is terminally ill, their spirituality may become very important as they search for meaning in the illness and suffering.
- The person may be looking for forgiveness and or acceptance or be reaching out to feel connected.
- To address this need you should use empathetic listening, contacting pastoral care or clergy if the patient asks, special rituals, praying with the patient,
music, meditation, or special readings.

ADDRESSING CULTURAL NEEDS

- Cultural values can influence a person’s openness to discussions regarding death and end of life healthcare preferences.
- End of life concerns are important to most people include comfort, open, accurate honest communications, ensuring needs are met, support, hope, and
optimism, forgiveness, honoring spiritual beliefs, and saying goodbye.
- There is some overlap between religious and cultural practices
- Some death rituals and expressions of grief may be culture based but not necessarily involve religion.

- Key Point: as with spiritual care, remember that you cannot assume that a person follows the practices their cultural group; you must assess
to be sure.
PROVIDING POSTMORTEM CARE
- Postmortem care includes care of the patient’s body after death and fulfilling any legal obligations, such as arranging transportation to the morgue or
funeral home and determining the disposition of the patient’s belongings.
- The provider must pronounce death, although a corner or a nurse may also perform this task.
- Changes in the body after death include the following:
- Rigor Mortis - is caused by contraction of the muscles from a lack of adenosine triphosphate. It occurs about 2 to 4 hours after death.
- Rigor mortis begins in the involuntary muscles, then in the head, neck and trunk, and finally in the extremities.
- It disappears about 96 hours after death.

- Algor Mortis - occurs when the blood stops circulating

- The body temperature drops about 1.88*F per hour until it reaches room temperature.

- Livor Mortis - occurs when the dependent parts of the body appear bluish and mottled.
- That happens when the blood stops circulating and the red blood cells break down, releasing hemoglobin.

- If the family wishes to be alone with the body, straighten the bed covers, remove all tubes and make the patient look as natural as possible.
- Give the family as long as they need before preparing the body.

PROVIDING GRIEF EDUCATION

- Reteach the stages of grief and point out that it may take months or even years to resolve.
- Explain that grief may become more intense on the anniversary of the death and on significant dates.
- Recall that once the bereaved person accepts that the loss is real, their feelings may be so intense that they may wonder whether they are losing their
sanity.
- Their grieving person may be fatigued from not sleeping, may be disoriented or unable to concentrate, and have numerous other symptoms.
HELPING CHILDREN DEAL WITH LOSS
- You may need to explain that children perceive death differently from adults and the importance of addressing death and grief with children.

TAKING CARE OF YOURSELF

- It is important to understand your own attitudes, fears, and beliefs concerning death, so think about these before you encounter dying patients.
- This will enable you to deal in a healthier way with patients and their family.
- Suppressing feelings associated with the death of patients can take a heavy toll on you emotionally.

- Recognize that feelings of grief and loss are normal. If you deny your feelings and focus on caring for others, you will begin to physically and mentally
wear down.

- Talk with other colleagues about your feelings. Nurses are known for being able to take care of everyone but themselves.
- Do not be afraid to ask for what you need.
- When away from work, do some nice things for yourself on a regular basis.
- Set aside a special relaxation spot in your home; decorate it with items that help you focus on peaceful thoughts candles, pictures, religious
objects.

- If you wish it is appropriate to attend calling hours and or funeral services when one of your patients dies to help diffuse some of your feelings or loss.