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Nursing Fundamentals - Comfort

Terms in this set (51)

Evidence Based Results
increased comfort, reduced stress, and healing environment = increased patient satisfaction and shorter hospital stays
Comfort Assessment (Subjective)
Interview info: description of symptoms, pain scale, report of lifestyle/sleep habits
Expected: no S/S of discomfort
Unexpected: pain, disrupted sleep patterns, nausea/vomiting, increase/decrease appetite, feelings of despair/anxiety
Comfort Assessment (Objective)
Assessment info: VS, physical assessment, diagnostic tests/labs
Expected: VS in range, no infection, no visible skin breakdown, lab results in range
Unexpected: increased heart rate, sweating, vomiting, sleep study shows apnea, blood/urine tests abnormal
Actual Tissue Damage
Pressure Ulcer
Potential Tissue Damage
burning yourself
Pain Duration
time frame
Pain Intensity
degree of severity (mild, moderate, severe)
Pain Quality
characteristics, description of sensation
Pain Location
where pain is experienced
Acute Pain
Sudden onset, duration usually less than 6 months
Chronic Pain
duration greater than 6 months, lasts beyond expected healing time
Breakthrough Pain
exacerbation of pain despite control measures; "end of dose meds"
Central Pain
caused by damage to nerves in CNS, described as "pins and needles"
Phantom Pain
sensation felt in amputated limb/body part
Psychogenic Pain
associated with psychological factors (mental/emotional issues) rather than physiological factors (injury/disease)
Somatic Acute Pain
pain that is musculoskeletal in nature; it is sharp and may accompany edema, cramps, or bleeding
Visceral Acute Pain
pain that occurs from internal organs, described as dull in nature, deep or aching
Referred Acute Pain
pain that is sensed in an area of the body that is not the site of origin
Clinical Manifestation (SNS "fight or flight")
increased BP
increased pulse
increase RR
diaphoresis
pallor
dilated pupils
Clinical Manifestation (visible symptoms)
crying
guarding
shielding site of injury
slow movements
Culture/Background Considerations of Pain
perception of pain
reaction to pain
expression of pain
willingness to request pain medication
type of treatment requested
Children
VS not reliable indicator
May cry inconsolably
By age 3, can express location/intensity
Adolescent
may have appetite change
may have sleep problems
may deny pain when with peers
Adult
may exhibit learned gender-specific behaviors
maybe ignore pain to not appear weak
Older Adult
may have increased pain threshold
may have lethargy
may have loss of appetite
Pain Collaborative Treatments
Diagnostic Tests
Surgery/Invasive therapies
Pharmacological Therapy
Pharmacological Therapy
Non-opioid Analgesics/NSAID's (OTC meds)
Opioid Analgesics (ranges from "weak" to "strong" effect)
Co-analgesics (used for another purpose but has analgesic effect)
Pain Independent Interventions
repositioning
massage
guided imagery
heat/ice
distraction
laughter
NREM sleep
four distinct stages; 75-80% of sleep cycle
REM sleep
lasts 5-30 mins; recurs about every 90 mins
NREM I
very light sleep
NREM II
body process continue to slow
NREM III and IV
deepest stages
essential for energy restoration
essential for growth hormone release
REM
brain is active (learning, thinking, and organizing regions)
Factors affecting Sleep
emotional stress
stimulants and alcohols
diet/nutrition
smoking
motivation
medications
illness/injury
Insomnia
trouble falling asleep or staying asleep
primary or secondary disorder
acute or chronic
causes drowsiness, irritability, fatigue, possible cognitive deficits
Sleep Apnea
repetitive periods of airway obstruction (complete or partial)
apneic episodes during sleep (lasts between 10-20 seconds)
Restless Leg Syndrome
neurological sensorimotor disorder
overwhelming urge to move legs
unpleasant sensations in legs
nighttime leg twitching
Sleep Collaborative Treatment
diagnostic tests
surgery
non-pharmacological therapy
pharmacological therapy
diagnostic tests (sleep)
polysomnography: records O2, HR, and RR
surgery (sleep)
tonsillectomy, adenoidectomy
non-pharmacological therapy (sleep)
CPAP/BiPAP
weight loss
bright light therapy
stimulus control therapy
sleep restriction
pharmacological therapy (sleep)
hypnotics/sedatives
Sleep Nursing Interventions
regular sleep/awake patterns
minimize environmental stimuli
restful environment
bedtime rituals
avoid fluid intake 90 mins before bedtime
regular exercise (not before bedtime)
Fatigue
associated with decrease in energy reserves (affects all basic body functions)
acute: associated with single event
chronic: more intense, lasts longer
Fatigue Pathophysiology
fatigue related to chronic illness may result from dysregulation of hormones
Fatigue Etiology
"underlying cause"
mood disorders
chronic illness
anemia
persistent pain
sleep disorders
pregnancy
meds
drug/alcohol use
grief
genetics
increasing age
Fatigue Symptoms
tiredness/drowsiness
exhaustion
apathy/lack of motivation
Fatigue Symptoms (less common)
muscle weakness
palpitations
dizziness
dyspnea
loss of appetite
blurry vision
difficulty concentrating
confusion
slowed reflexes
depressed mood
Fatigue Collaborative Treatments
diagnostic tests
surgery/invasive therapies
pharmacological therapy
Fatigue Nursing Interventions
encouraging sleep hygiene
encourage activity
schedule challenging activities during patients best time of day
assist with self-care activities as needed
help set short/long term goals
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