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NURS1202 Tutorial Study notes Tutorial 1: vital signs, patient admission, pain assessment, ISBAR Between the Flags: https://www.cec.health.nsw.gov.au/keep-patients-safe/Deteriorating-patientprogram/between-the-flags • Created by the CEC • It is designed to protect these patients from deteriorating unnoticed and to ensure they receive appropriate care if they do. • Acknowledging that early recognition of deterioration can reduce harm to patients and the earlier the better. • Establishing vital sign thresholds (calling criteria) for escalation and a clinical response team with advanced life support skill PQRST Pain assessment tool: • Pain is subjective • Self-report is considered the Gold Standard and most accurate measure of pain • Describe, assess & document • Documentation: o Patient’s understanding of the pain scale o Patient satisfaction with the pain level with current treatment modality o Timely re-assessment following any intervention and response to treatment o Communication with the physician o Patient education provided and the patients response to learning Vital Signs: • Core nursing foundation and key to the recognition of patient deterioration • Timely and accurate assessment, documentation and interpretation of vital signs is critical to clinical reasoning, accuracy of nursing diagnosis and implementation of appropriate interventions o Respirations: § Should be assessed when the person is relaxed § Rate, depth, rhythm, quality and effectiveness – breaths/minute § Normal range = 12-20 (adults) § Factors affecting: [increase] exercise, anxiety, stress, increased environmental temperature, lowered oxygen conc. at increased altitudes. [decrease] low environmental temperature, medications, increase ICP • Rate: b/min o Tachypnoea – quick, shallow o Bradypnoea – abnormally slow o Apnoea – cessation of breathing •

Volume: o Hyperventilation – overexpansion of lungs, characterised by rapid/deep breaths o Hypoventilation – underexpansion of lungs, characterised by shallow breaths

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Rhythm: o Cheyne strokes – waxing and waning of respirations, from very deep to very shallow & temporary apnoea Ease/effort: o Dyspnoea – difficult/laboured. Individual has persistent, unsatisfied need for air and feels distress o Orthopnoea – ability to breath only sitting upright/standing positions Stridor: a shrill, harsh sound heard during inspirations with laryngeal obstruction Stertor: snoring or sonorous respirations, usually due to partial obstruction of upper airway Wheeze: continuous, high-pitched musical squeak/whistling sound occurring on expiration and sometimes on inspiration when air moves though narrow/partially obstructed airway Bubbling: gurgling sounds hears as air passes through moist secretions in the respiratory tract

Chest movements: o Intercostal retraction – indrawing between the ribs o Substernal retraction – indrawing beneath the breastbone o Suprasternal retraction – indrawing above the clavicles • Secretions/coughing: o Haemoptysis – blood in sputum o Productive – cough with secretions o Non-productive – dry cough with no secretions Oxygen Saturation: § Oxygen is carried in the blood as either dissolved oxygen or oxygen bound to haemoglobin in RBCs. § Normal range = >95% § The conc. of oxygen dissolved in the plasma is: partial pressure of arterial oxygen [PaO2] § The ratio of oxygen bound to haemoglobin compared with the oxygen-carrying capacity of the haemoglobin is: saturation of arterial oxygen [SaO2] § Oxygenation is measure as a correlated of the Pa02 & the Sa02 § Measure with a pulse oximeter • Two light-emitting diodes (LEDs) – one red and the other infrared – transmit light though nail, tissues, venous and arterial blood • Photodector placed directly opposite the LED – measure the amount of red and infrared light absorbed by oxygenated and deoxygenation blood and reports it as SaO2 § Factors affecting: haemoglobin, circulation, activity, dark-coloured nail polish/discolouration of nail bed, carbon monoxide poisoning Blood Pressure: § Measure of the pressure exerted by the blood as it flows through the arteries • Systolic: pressure as a result of ventricular contraction • Diastolic: pressure when the ventricles are at rest • Pulse pressure: the different between the diastolic and systolic •

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Normal range = 120/80mmHg o Hypertension: persistent above normal. § Diastolic = >90mmHg § Systolic = >140mmHg

NURS1202 Tutorial Study notes Lack of physical exercise, heavy alcohol consumption, smoking, obesity o Hypotension: § Systolic = 85-110mmHg o Postural/Orthostatic hypotension: § Decline in SBP of at least 20mmHg & decline of DBP of 10mmHg within 3 minutes of standing o Cardiac output: the amount of blood the heart mechanically pumps out. Weak = lower CO [BP decreases], strong = high CO [BP increases} o Stroke volume: decrease in volume (haemorrhage/dehydration) = decrease in BP. Increase in volume (rapid IV infusion) = increase in BP o Peripheral vascular resistance: peripheral resistance = increase in BP (especially diastolic). § Factors that create resistance – capacity of the arterioles and capillaries, the compliance of the arteries and viscosity, internal diameter/capacity of arterioles/capillaries – small space within a vessel = greater resistance. § Vasoconstriction from smoking, or obstruction of arteriosclerosis increase PVR o Blood viscosity: BP increases when the blood is highly viscous (thick) – ratio of RBCs : blood plasma = high [ratio is called haematocrit]. Viscosity increases when haematocrit is >60-65% Factors affecting: age, exercise, stress, ethnicity, gender, medications, obesity, diurnal variations, disease process, hypo/hypervolaemia Assessing BP: • Sphygmomanometer & stethoscope • Measure brachial artery (upper arm) o Phase 1: [140-130] A sharp tapping o Phase 2: [130-120] A swishing or whooshing sound o Phase 3: [110-100] A thump softer than the tapping in phase 1 o Phase 4: [100-90] A softer blowing muffled sound that fades o Phase 5: [100 Bradycardia = 2) over a 24 hr period o Relapsing fever – short febrile periods of a few days interspersed with periods of 1 or 2 days of normal temp o Constant fever – fluctuates minimally but always remains above normal • hyperpyrexia – above 41 • Hyperthermia – C.temp greater than 40.6 • hypothermia – below normal temp (36.5) o excessive heat loss

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inadequate heat production to counteract heat loss impaired hypothalamic thermoregulation § decreased: temp, RR, PR, BP § shivering initially and then none § feeling cold/chills § pale/cool/waxy skin § frostbite § oliguria § lack of muscle coordination § disorientated § drowsiness à coma

Pain management: • unpleasant and highly subjective/personal/emotional experience associated with actual or potential tissue damage •

Types of pain: o Location: based on where it is in the body. determines the person’s underlying problems or needs § radiating pain: spread/expand to other areas – from lower back down to legs § referred pain: arising in different areas – cardiac pain in left arm/shoulder § visceral pain: arising from organs or hollow viscera § cancer pain: result from direct effects of the disease and its treatment o Duration: § Acute pain: sudden onset, sympathetic NS response, tissue injury/resolves with healing, crying, rubbing area, holding area § Chronic pain: +6months, parasympathetic NS response (normal v/s), dry/warm skin, pupils normal or dilated, continuous beyond healing, often doesn’t mention pain, behaviour absent o intensity: scale 1-10 o Aetiology: § physiological pain: experienced when an intact, properly functioning NS sends signals that tissues are damaged, requiring attention and proper care. • Somatic pain: originates in the skin, muscles, bone or connective tissue. (Sharp sensation of a paper cut or aching of a sprained ankle) • Visceral pain: results from activation of pain receptors in the organs/hollow viscera (tends to be poorly located – cramping, throbbing, pressing or aching. nausea, sweating, vomiting) • Neuropathic pain: damaged or malfunctioning nerves. may be abnormal due to illness, injury, or undetermined reasons. o peripheral neuropathic pain: phantom limb, post-herpetic neuralgia, carpal tunnel syndrome o central neuropathic pain: spinal cord injury pain, post-stroke pain, MS pain o Sympathetically maintained pain: abnormal connections between pain fibres and the sympathetic NS perpetuate problems with both the pain and sympathetically controlled functions (e.g. oedema, temp, blood flow regulation) o Concepts associated with pain: § pain threshold – least amount of stimulus that is needed for a person to label a sensation as pain

NURS1202 Tutorial Study notes pain tolerance – the maximum amount of painful stimulus that a person is willing to/able to withstand without seeking relief § hyperalgesia/hyperpathia – heightened response to a painful stimulus § allodynia – non-painful stimuli produces pain § dysesthesia – unpleasant/abnormal sensation – mimics/imitates the pathology of a central neuropathic pain disorder Physiology of pain: o nociception: refers to a signal arriving at the central nervous system as a result of the stimulation of specialised sensory receptors (nociceptors) in the peripheral nervous system § transduction: nociceptors can be excited by mechanical/thermal/chemical stimuli. • trigger the release of biochemical mediators (prostaglandins, bradykinin, serotonin, histamine, substance P) that sensitise nociceptors. • Noxious/painful stimulation also causes movement of ions across cell membranes that also excite nociceptors. §

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Analgesics (ibuprofen/aspirin) block the production of prostaglandin (local anaesthetic) by decreases the movement of ions across the cell membranes transmission: 2nd process of nociception “transmission of pain” • 1st segment – pain impulse travels from the peripheral nerve fibres to the spinal cord (PNSàCNS) • Substance P (as a neurotransmitter) enhances the movement of impulses across the nerve synapse from the primary afferent neuron à second-order neuron in the dorsal horn of the spinal cord o 2 types of nociceptor fibres causes this transmission to the dorsal horn of the spinal cord: § unmyelinated C fibres – transmit dull/aching pain § thin A-delta fibres – sharp/localised pain o In the dorsal horn, the pain signal is modified by modulating factors (excitatory amino acids/endorphins) before the amplified or dampened signal travels via the spinothalamic tracts. nd • 2 segment – from the spinal cord and ascension, via spinothalamic tracts, à the brain stem à thalamus • 3rd segment – involves transmission of signals between the thalamus à somatic sensory cortex (where pain perception occurs) modulation: “descending system” • neurons in the thalamus/brain stem send signals back down to the dorsal horn of the spinal cord o descending fibres release substances (endogenous opioids, serotonin and noradrenalin) o inhibit (dampen) the ascending noxious impulses in the dorsal horn § [in contrast] excitatory amino acids (glutamate, N-methyl-daspartate (NMDA) and the up-regulation of excitatory glial cells can amplify these pain signals. the effects of the excitatory amino acids/glial cells tend to persist, while effects of the of the inhibitory neurotransmitters tend to be short-lived as they are reabsorbed into the nerves § Tricyclic antidepressants block the re-uptake of noradrenaline and serotonin •

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NURS1202 Tutorial Study notes NMDA antagonists (ketamine, dextromethorphan) may be used to help diminish the signals of pain perception: person becomes conscious of the pain. • the sum of complex activities in the CNS that may shape the character and intensity of pain perceived and ascribe meaning to the pain o psychological context of the situation and the meaning of pain based on past experiences/further hopes help to shape the behavioural response that follows §

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Responses to pain: o physiological: § activation of the sympathetic NS § increase in HR/BP, short/shallow breathing § reflexive movements – withdrawing from painful stimuli § stop activity, tense muscles • muscle atrophy/painful spasm à cardiac deconditioning, immobility § impairs immune function à slows healing, increases susceptibility to infections/dermal ulcers o psychological: § interferes with sleep, lowers appetite, decreases quality of life

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Factors affecting the pain experiences: o Cultural values § influence a person’s reaction to pain and the expression of pain – some cultures are more prone to expressing pain than others § Middle Eastern/African – self-infliction is a sign of mourning § pain may be anticipated as part of the ritualistic practices à tolerance to pain signifies strength and endurance § Northern European – more stoic and less expressive of pain than Southerners • Nursing implications: o understand the effect of their own values and expectations about pain and ensure that they take steps to assess/evaluate these attitudes, so they do not make assumptions about the pain experienced by people o be sympathetic to concerns and develop skills needed to interact and communicate effectively and to undertake care that is culturally inclusive o Developmental stage: § Infants and children • less able than adults to articulate their experience tor needs = pain untreated • behavioural observations • environmental/non-pharmacological/pharmacological interventions are used to prevent, reduce and eliminate pain in neonates and children § Pubescent – growing pains, period pains § Women – more headaches, fibromyalgia, lupus § Men – more occupational/risk-taking behaviours § Older – increase prevalence of acute/chronic illness • Nursing implications: o very old/young, women, and ethnic minorities are at higher risk of being untreated for their pain Assessing pain: o Pain history: to help understand what pain means for the individual and how they are coping with it

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NURS1202 Tutorial Study notes COLDERR – character, onset, location, duration, exacerbation, relief, radiation PQRST effect on ADLs • previous pain treatments and effectiveness • when and what analgesics were last taken • other medications being taken • allergies to medications o Location: § point to specific area § picture of body to drawn on – good for people with more than 1 source o Pain intensity/Rating scale: § 0-10 numeric scale § Wong-Baker face scale (for people with impaired cognition/communication/do not speak English) o Pain quality: § pain – searing, scalding, sharp, piercing, shooting, burning, crushing, penetrating / killing, intense, terrifying, exhausting, suffocating § hurt – pricking, pressing, tender / heavy, throbbing § ache – numb, cold, radiating, dull, sore, aching, cramping / annoying, nagging, uncomfortable, sickening, tender o Pattern: § time of onset, duration, and recurrence or intervals without pain o Precipitating factors: § identifying these can help prevent pain • physical exertion à chest pain/muscle spasms • eating à abdominal pain • cold/damp days à rheumatic conditions • strong emotions à headaches, chest pain o Alleviating factors: § describe anything done to help • home remedies – herbal teas, medications, rests, heat/ice packs, TV distraction, prayer § worse or better o Associated symptoms: § nausea, vomiting, dizziness, diarrhoea – onset or presence of pain o Effect on ADLs: sleep, appetite, concentration, work/school, interpersonal relationships, marital relations/sex, home activities, driving/walking, leisure activities, emotional status o Coping resources: seeking quiet and solitude, learning about their condition, pursuing distractions, prayer, social support o Affective response: vary according to the situation, degree and duration, interpretation, and may other factors. Feelings of anxiety, fear, exhaustion, depression, failure, etc. o Observation of behavioural/physiological responses: verbal/non-verbal § immobilisation of body part § purposeless body movements § behavioural changes § rhythmic body movements § sympathetic NS responses Pharmacological pain management: § § §

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NURS1202 Tutorial Study notes Non-opioid analgesics/NSAIDs: § acetylsalicylic acid (aspirin) § paracetamol (Panadol) § diclofenac sodium (voltaren) § ibuprofen (neurofen) § naproxen sodium (naprogesic) § celecoxib (Celebrex) § meloxicam (Mobic) • Non-opioids [paracetamol]: analgesic, antipyretic effects – different MOA • NSAIDs: anti-inflammatory, analgesic, antipyretic effects o Anti-inflammatory action relieves pain by interfering with the cyclooxygenase (COX) chemical cascade that is activated by damaged tissue o Opioid analgesic § [moderate pain] • dextropropoxyphene • codeine phosphate • paracetamol and codeine phosphate (Pandeine) • tramadol (tramal) § [severe pain] • fentanyl citrate (sublimaze, transdermal patches) • hydromorphone hydrochloride (dilaudid) • morphine sulfate (morphine, MS contin) • Methadone (physeptone) • oxycodone hydrochloride (endone) § Full agonists: bind tightly to mu receptors on situ, producing maximum pain inhibition (morphine, oxycodone, etc) § Partial agonists: have a celling effect in contrast with full agonists. Block the mu receptor or are neutral at the receptor but bind to the kappa receptor site. o Side effects: respiratory depression, sedation, nausea/vomiting, urinary retention, blurred vision, sexual dysfunction, constipation o Co-analgesics § Tricyclic antidepressants (Amitriptyline) § Anticonvulsants (Carbamazepine) § Topical local anaesthetic (lignocaine) Non-pharmacological pain management o physical interventions o cutaneous stimulation – rubbing o massage o heat/cold application o acupressure – pressure pints o contralateral stimulation – stimulating skin in an area opposite the painful area o immobilisation/bracing o Transcutaneous electrical nerve stimulation (TENS) – applying a low-voltage electrical stimulation directly over identified pain areas o cognitive-behavioural interventions – altering psychological response to reduce pain perception and optimise functioning [includes the below 4] o distractions – TV o eliciting the relaxation response – decrease stress o

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re-patterning unhelpful thinking facilitating coping – emotional/problem focused coping strategies selected spiritual interventions – rituals to make individual apart of the community or feel a bond with the universe non-pharmacological invasive therapies – nerve block

ISBAR: • The ISBAR framework represents a standardised approach to communication which can be used in any situation • ensures completeness of information and reduces likelihood of missed data • improves communication between healthcare professionals o I: introduction – Who you are, your role, where you are and why you are communicating o S: Situation – What is happening at the moment? o B: Background – what are the issues that led up to the situation? o A: Assessment – what do you believe is the problem? o R: Recommendations – what should be done to correct this situation?

NURS1202 Tutorial Study notes Tutorial 2: medication schedules, medication charts, drug register Schedule of drugs:

Drug Register: Drugs of Addiction •

The Ward Drug Register must be used to record the receipt, administration and supply of Schedule 8 medication (drugs of addition) with a witness in health facility patient care areas (wards/clinic/units) under the NSW Poisons and Therapeutic Goods legislative requirements.

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Transferring the balance: o the person who made the last entry on the pervious page must record the transfer to the new page with the witness Recording the amount of schedule 8 medications: o Liquids – mL (not mg) o Solid dose forms – discrete units (e.g. 1 or 0.5 if the medication is suitable to be given as a part tablet) o Ampoules – discrete units OR as the dose (10mg or 5mg) in accordance with the local protocol o Patches: discrete units M...