Nursing Concepts (NSG 3313)
Nursing Concepts (NSG 3313) NSG 3313
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Chapter 44: Activity and Exercise, p. 1122 Concepts Exam 1 Normal Movement o Alignment and posture—proper body alignment and posture bring body parts into position in a manner that promotes optimal balance and maximal body function whether the client is sitting, standing, or lying down. Line of gravity—an imaginary vertical line drawn through the body’s center of gravity. A patient will maintain balance as long as this passes through their center of gravity Center of gravity—the point at which all of the body’s mass is centered Base of support—the foundation on which the body rests. The wider the base of support, the better o Joint mobility Range of motion (ROM)—the maximum movement that is possible for that joint o Balance—the mechanisms involved in maintaining balance and posture are complex and involve information inputs from the labyrinth (inner ear), from vision (vestibule-ocular input), and from stretch receptors of muscles and tendons (vestibulospinal input). Mechanisms of equilibrium respond, frequently without our awareness, to various head movements Proprioception—the term used to describe awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body o Coordinated movement Exercise—a type of physical activity defined as a planned, structured, and repetitive bodily movement performed to improve health and maintain fitness to achieve an optimal state of health o Activity tolerance—the amount and type of exercise or daily living activities an individual is able to perform without experiencing adverse effects Activities of Daily Living (ADLs) Types of Exercise o Isotonic (dynamic)—exercise in which the muscle shortens to produce muscle contraction and active movement. Increase muscle tone, mass and strength and maintain joint flexibility and circulation. Both heart rate and cardiac output quicken to increase blood flow to all parts of the body o Isometric (static or setting)—those in which there is muscle contraction without moving the joint (muscle length does not change) o Isokinetic (resistive)—can be either isotonic or isometric; involve muscle contraction or tension against resistance. o Aerobic—activity during which the amount of oxygen taken into the body is greater than used to perform the activity. Improves cardiovascular conditioning and physical fitness 1 Benefits of exercise—if you understand benefits, you will understand side- effects of immobility o Musculoskeletal—increases bone density and strength by increasing osteoblasts o Cardiovascular—decreases BP & cholesterol. Increases HR, the strength of heart muscle contraction, and the blood supply to the heart and muscles through increased CO. o Respiratory—increases ventilation, oxygen intake, and gas exchange. Prevents pooling of secretions in the bronchi and bronchioles, decreasing breathing effort and risk of infection. o Gastrointestinal—improves appetite and increases GI tract tone, facilitating peristalsis o Metabolic/Endocrine—elevates the metabolic rate, increasing the production of body heat and waste products and calorie use o Urinary—increases effectiveness of waste excretion; prevents stasis of urine, which decreases risk for UTIs o Immune—moderate exercise enhances immunity, but a pattern of strenuous exercise may reduce immune function if adequate rest is not provided after vigorous training o Psychoneurologic—can relieve depression; improves quality of sleep o Cognitive—improves mood, learning, problem solving, and performance for all ages o Spiritual—improves mind-body-spirit connection, relationship with God, and physical well-being Factors Affecting Body Alignment & Activity o Growth and development—gross motor development occurs in a head- to-toe fashion. From 6-12, refinement of motor skills continues and exercise patterns for later life are generally determined. Initially, walking involves a wide stance and unsteady gait, thus the term toddler. Pregnancy alters the center of gravity and affects balance As age advances, muscle tone and bone density decrease, joints lose flexibility, reaction time slows, and bone mass decreases o Physical health—some can’t tolerate exercise o Mental health—confused, depressed o Nutrition—undernutirion and overnutrition can influence body alignment and mobility o Personal Values and Attitudes o External factors—money, time, temperature o Prescribed limitations Bed rest—in some agencies bed rest means strict confinement to bed or “complete” bed rest. Others may allow the client to use a bedside commode or have bathroom privileges Effects of Immobility Musculoskeletal System o Disuse osteoporosis—without the stress of weight-bearing activity, the bone demineralizes o Disuse atrophy—unused muscles atrophy (decrease in size), losing most of their strength 2 o Contractures—when the muscle fibers are not able to shorten and lengthen, eventually a contracture (permanent shortening of the muscle) forms, limiting joint mobility o Stiffness and pain in the joints—without movement, the collagen tissues at the joint become ankylosed (permanently immobile) Cardiovascular System o Diminished cardiac reserve—tachycardia w/ minimal cavity o Increased use of the Valsalva maneuver—refers to holding the breath and straining against a closed glottis. Cardiac arrhythmias can result o Orthostatic (postural)hypotension—common result of immobilization; syncope Drop of 20mmHg or more systolic and of 10mmHg or more in diastolic when position changes from lying to sitting or standing Due to decreased circulating blood volume, decreased autonomic response, increased pooling of blood in lower extremities o Venous vasodilation & stasis—clots o Dependent edema—when the venous pressure is sufficiently great, some of the serous part of the blood is forced out of the blood vessel into the interstitial spaces surrounding the blood vessel, causing edema o Thrombus formation—accumulation of platelets, fibrin, clotting factors, and cellular debris. Can cause PE, heart attack, or stroke. Factors that contribute: injury to vessel wall, stasis of blood flow, changes in blood components Respiratory System o Decreased respiratory movement—immobility can cause the cartilaginous intercostal joints to become fixed in an expiratory phase, further limiting the potential for maximum ventilation. These changes produce shallow respirations and reduce vital capacity (the maximum amount of air that can be exhaled after a maximum inhalation). o Pooling of respiratory secretions—interferes with the normal diffusion of oxygen and carbon dioxide in the alveoli o Atelectasis—decreased surfactant and blockage of a bronchiole with mucus can cause atelectasis (the collapse of a lobe or of an entire lung) distal to the mucous blockage. Immobile older, postoperative clients are at greatest risk of atelectasis o Hypostatic pneumonia—pooled secretions can cause a minor upper respiratory infection to rapidly evolve into a severe infection of the lower respiratory tract. This pneumonia can severely impair oxygen- carbon dioxide exchange in the alveoli and is a fairly common cause of death among weakened, immobile persons Metabolic System o Decreased metabolic rate—basal metabolic rate (minimal energy expended for the maintenance of metabolism) and GI mobility and secretions decrease as energy requirements of the body decrease o Negative nitrogen balance—immobility creates a marked nitrogen imbalance, and the catabolic processes (protein breakdown) exceed the anabolic processes (protein synthesis) 3 o Anorexia—loss of appetite (anorexia) occurs because of the decreased metabolic rate and the increased catabolism that accompany immobility o Negative calcium balance—greater amounts of calcium are extracted from bone than can be replaced. Urinary System o Urinary stasis—stoppage or slowdown of urine flow. Bladder emptying is compromised because of the horizontal position of the patient o Renal calculi—the calcium and citric acid balance is disrupted, leading to alkaline urine and kidney stones o Urinary retention—accumulation of urine in the bladder. Urinary incontinence may accompany this. Associated with decreased muscle tone of urinary bladder, discomfort of suing bedpan, embarrassment and lack of privacy associated with this function, and unnatural position for urination o Urinary infections—caused by stagnant urine from urinary retention Gastrointestinal System o Constipation—caused by decreased peristalsis and colon motility. The unnatural position, embarrassment, lack of privacy, and disruption of normal bowel habits associated with using a bedpan could also affect this Integumentary System o Reduce skin turgor—increased atrophy and shifts in body fluids o Skin breakdown—immobility impedes circulation and diminishes the supply of nutrients to specific skin areas. Formation of ulcers can occur Psychoneurologic System o Decrease in self-esteem and role performance Assessment—see Assessment Interview: Activity & Exercise, page 1139 o Nursing history—subjective; info from above table o Physical examination—objective Gait—how a person walks. Assessed to determine client’s mobility and risk for injury due to falling. May also assess pace (number of steps taken per minute), which often slows with age and disability. Normal is 70-100, elderly is 40 Appearance and movement of joints—exam involves inspection, palpation, assessment of range of active motion, and if active motion is not possible, range of passive motion. Should assess for crepitation (palpable or audible crackling or grating sensation produced by joint motion and frequently experienced in joints that have suffered repeated trauma over time Capabilities and limitations for movement—nurse must gain info that may indicate hindrances or restrictions to the client’s movement and the need for assistance Muscle mass and strength Activity tolerance—by determining an appropriate activity level for a client, the nurse can predict whether the client has the strength and endurance to participate in activities that require similar expenditures of energy. This is useful in encouraging 4 increasing independence in people who have a cardiovascular or respiratory disability, have been completely immobilized for a prolonged period, have decreased muscle mass or a musculoskeletal disorder, have experienced inadequate sleep, have experienced pain, or are depressed, anxious, or unmotivated Problems related to immobility—nurse needs to identify clients at risk for developing complications of immobility. Those at risk include those who are poorly nourished; have decreased sensitivity to pain, temperature, or pressure; have existing cardiovascular, pulmonary, or neuromuscular problems; and have altered level of consciousness. See Table 44-3, Assessing Problems of Immobility, page 1142 Diagnosing (page 1143, see page 1176-1178 for Care Plan) o Activity Intolerance: Level I, Level II, Level III, Level IV o Risk for Activity Intolerance o Impaired Physical Mobility Impaired Bed Mobility, Impaired Transfer Ability, Impaired walking, Impaired Wheelchair Mobility o Sedentary Lifestyle—low physical activity o Risk for Disuse Syndrome Planning—goals and outcomes; important to include patient in planning to ensure they value the goals o Examples: participates in prescribed activity, expresses understanding of balancing rest and activity Implementing—nurses can initiate and apply a wide variety of exercise and activity interventions as needed to address a multitude of client concerns o Using body mechanics—body mechanics is the term used to describe the efficient, coordinated, and safe use of the body to move objects and carry out the ADLs. They need a wide base of support and low center of gravity o Lifting—not more than 35 pounds o Pulling and pushing—pulling is easier o Pivoting—avoid o Preventing back injury—two movements to avoid because of their potential for causing back injury are twisting (rotation) of the thoracolumbar spine and acute flexion of the back with hips and knees straight (stooping). Review Client Teaching: Preventing Back Injuries, page 1148 Positioning clients—positioning a client in good body alignment and changing the position regularly (every 2 hours) and systematically are essential. Also ensure client comfort and safety while positioning them, use two or more nurses to turn the client o Review Box 44-1 Support Devices, page 1148 Positions o Fowlers position—a semi-sitting position, is a bed position in which the head and trunk are raised 45-60 degrees in relative to the bed. Typically it refers to a 45° angle. Used for people who have difficulty breathing and for some people with heart problems 5 Low—15-45° Semi—45-65°--also called low; in the book it says 15-45° High—90°; in the book it says 60-90° o Orthopneic position—client sits either in bed or on the side of the bed with an overbed table across the lap. Facilitates respiration by allowing maximum chest expansion o Dorsal recumbent position—the client’s head and shoulders are slightly elevated on a small pillow. The supine or dorsal position, the head and shoulders are not elevated o Prone position—the client lies on the abdomen (stomach) with the head turned to one side. Should be used only when the client’s back is correctly aligned, only for short periods, and only for people with no evidence of spinal abnormalities o Lateral position (side-lying)—the client lies on one side of the body (left). Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability. Used for enemas o Sims’ Position (semi-prone)—the client assumes a posture halfway between lateral and the prone positions Review the following: Skill 44-1: Moving a client up in bed. Skill 44-2: turning a client to the lateral or prone position in bed. Skill 44-3: Logrolling a client. Skill 44-4: Assisting the client to sit on the side of the bed (dangling). Skill 44- 5: Transferring between bed and chair. Skill 44-6: Transferring between bed and stretcher. Skill 44-7: Assisting the client to ambulate. Providing ROM Exercises o Active—client moves joints through complete range of movement. Exercises are isotonic and maintain or increase muscle strength and endurance and help to maintain cardiorespiratory function in immobilized client o Passive—another person moves the client’s joints through its complete range of motion. Only to the point of slight resistance. Because the client doesn’t contract the muscles, they are of no value in maintaining muscle strength, but are useful in maintaining joint flexibility Assisting a Client to Walk (ambulate) o Need to know a lot about the patient before ambulating them: prior info, needs, environment, illness, etc. o Assess orientation. Evaluate the environment for safety and establish rest points. Ensure the client wears non-skid shoes. Support client at the waist o Ensure client dangles on side of bed for 1-2 minutes before walking to prevent syncope Assisting a Client to Fall o Stand with feet apart to provide broad base of support, extend one leg and let client slide against it to the floor. Bend knees to lower body as client slides to the floor. Assistive Devices o Walkers—more effective because they have a wider base of support o Canes—length should be the distance between the greater trochanter and the floor 6 Kept on the strong side of the body Place cane forward 6-10 inches, move weaker leg forward, move the stronger leg forward past the cane, then repeat o Crutches—see Teaching: Client Care, Using Crutches, page 1172 With axillary crutches, be sure there is 3-4 finger widths between crutch pad and clients axilla Crutch length is measured from axilla to floor 7 Chapter 41: Spirituality, p. 1050 Concepts Exam 4 SPIRITUALITY The part of being human that seeks meaningfulness through intra-inter- and transpersonal connection. “That most human of experiences that seeks to transcend self and find meaning and purpose through connection with others, nature, and/or a Supreme Being, which may or may not involve religious structures of traditions Highly personal and highly individualized The nurse must also be aware of his/her own spiritual beliefs Involves a belief in a relationship with some high power, creative force, divine being, or infinite source of energy Includes: o Meaning-having a purpose or sense o Value-having beliefs that are important to the person o Transcendence- believing in something bigger controlling things o Connecting- relating to others, nature, or ultimate other o Becoming-allowing yourself to be spiritual Spiritual Needs: Box 41-1, p. 1060 o Needs related to the self: Need for meaning and purpose, hope, personal dignity, gratitude, vision Need to express creativity, transcend life challenges, prepare for and accept death o Needs related to others: Need to forgive others and to cope with loss of loved ones o Needs related to the Ultimate Other: Need to be certain there is a God or Ultimate Power in the universe; to believe that God is loving, and personally present; and to worship o Needs among and within groups: Need to contribute or improve one’s community, be respected and valued, and know what and when to give and take o Illness often challenges beliefs even in those with a strong spiritual base Spiritual Well-Being o Spiritual health—a way of living, a lifestyle that views and lives life as purposeful and pleasurable, that seeks out life-sustaining and life- enriching options to be chosen freely at every opportunity, and that sinks its roots deeply into spiritual values and/or specific religious beliefs o Feeling generally alive, purposeful, and fulfilled o Can be achieved in many different ways (prayer, meditation, dance) o Not just about RELIGION Spiritual Distress 1 o A challenge to the spiritual well-being or to the belief system that provides strength, hope, and meaning to life. Can be a NANDA diagnosis o Defining characteristics of spiritual distress (many are S/S of complicated grieving): Express lack of hope, meaning and purpose in life, forgiveness of self Expresses being abandoned by or having anger toward God Refuses interaction with friends, family Sudden changes in spiritual practices Requests to see a religious leader No interest in nature, or reading spiritual literature RELIGION An organized system of beliefs and practices – often dictated by culture A specific system of practices associated with a particular denomination, sect, or form of worship Offers a way of spiritual expression that provides guidance for believers to respond to life’s questions and challenges Organized religions offer: o A sense of community bound by common beliefs o The collective study of scripture o The performance of ritual o The use of disciplines and practices, commandments, and sacraments o Ways of taking care of the personal spirit Agnostic—person that DOUBTS the existence of God; believes that existence of a higher power can’t be proved or disproved Atheist—one without belief in God Monotheism—the belief in the existence of one God Polytheism—the belief in the existence of many Gods FAITH To believe or to be committed to something or someone Provides strength and hope A relationship with divinity, higher power, authority, or spirit that incorporates belief of action Hope—a process of anticipation that involves the interaction of thinking, acting, feeling, and relating, and is directed toward a future fulfillment that is personally meaningful Loss of faith or hope can be seen in pt by rapid wasting or decline of pt Transcendence—thee capacity to reach out beyond one’s self Recognizing that there is something greater than you and seeking and valuing that force SPIRITUAL DEVELOPMENT Occurs during life stages Table 41-1: Stages of Spiritual Development, p. 1061 o 0-3 years: acquire fundamental spiritual qualities of trust, mutuality, courage, hope, love o 3-7 years: fantasy-filled, imitative; child influenced by examples, moods, actions. Make-believe is experienced as reality 2 o 7-12 years, even into adulthood: attempts to sort fantasy from fact by demanding proofs or demonstrations of reality o Adolescence: generally conform to beliefs of those around them, begin to examine beliefs objectively o Young Adulthood: forms individual commitments, lifestyle, beliefs, and attitudes; begins to develop personal meaning for symbols of religion and faith o Mid-Adulthood: newfound appreciation for the past, increased respect for inner voice o Mid- to Late Adulthood: able to believe in, and live with a sense of participation in, a nonexclusive community. May work to resolve social, political, economic, or ideological problems in society. Embrace life, yet hold it loosely o Read Lifespan Considerations: Spiritual Development, p. 1062 SPIRITUAL PRACTICES AFFECTING NURSING CARE Holy Days—days set aside for special religious observance, and all the world religions observe certain holy days Sacred Writings—authorities scriptures that provide guidance for its adherents’ beliefs and behaviors; frequently tell instructive stories of the religion’s leaders, kings, and heroes o People often gain strength and hope from reading religious writings when they’re ill or in crisis Sacred Symbols—include jewelry, medals, amulets, icons, totems, or body ornaments that carry religious or spiritual significance o May be worn to pronounce one’s faith, to remind the practitioner of the faith, to provide spiritual protection, or to be a source of comfort or strength o Hospitalized pts or long-term care pts may wish to have the spiritual icons or statues with them as a source of comfort Prayer and Meditation o Prayer—human communication with divine and spiritual entities o Meditation—the act of focusing one’s thoughts or engaging in self- reflection or contemplation Beliefs Affecting Diet and Nutrition o Most religions lift the fasting requirements for seriously ill believers whom fasting may be a detriment to health Beliefs Related to Healing, Dress, Birth, and Death o When relevant, nurse should assess pt’s beliefs related to health and, if possible, include some aspects of healing that are part of pt’s belief system in the planning of care. o When nurses are aware of religious needs of families and their infants, they can assist families in fulfilling their religious obligations. His is especially important when the newborn infant is seriously ill or in danger of dying because some people believe that if religious obligations are not fulfilled the infant will not be accepted into the community of the faithful after death. o Observance of special rituals surrounding dying and death provides comfort to the dying person and their loved ones. 3 As nurses we should be assessing these practices and discussing their implications on patient care with providers and patients o Nurses should facilitate these practices if possible What about the nurse sharing personal beliefs or practices? o Before sharing personal beliefs or practices, a nurse must consider the following: For what purpose am I sharing my beliefs or practices? By doing so, am I meeting my needs or my pt’s needs? Is my spiritual care reflecting a spiritual assessment? Am I preying on a vulnerable client? Am I offering my beliefs or practices in a manner that allows my pt to refuse comfortably? Does my spiritual care hurt or contribute to a therapeutic relationship with the pt? o On the reverse side, as a nurse you do not have to participate in any practices that make you uncomfortable or that conflict with your beliefs SPIRITUAL HEALTH AND THE NURSING PROCESS Assessment o Nursing History—see Assessment Interview, p. 1066: 3-tiered approach Initially, the nurse assesses if pt accepts a spiritual reality. If yes, then the pt can be asked general questions to elicit information about beliefs and practices are important to the present health care situation and what, if anything, the pt would like from the health care team to support spiritual health. Then, those who manifest some type of unhealthful spiritual need or are at risk for spiritual distress can be assessed more thoroughly FICA—faith or beliefs, implications or influence, community, address o JCAHO mandates that all pts have a spiritual assessment; ethical and legal responsibility o Warnings about spiritual assessments: It’s assumed that spirituality can be assessed, and that nurses are appropriate clinicians for conducting initial or relatively superficial level of assessment. Both assumptions, however, may be debated A nurse-conducted spiritual assessment should be done only if it has a purpose related to providing health care Nurses should never assume that a pt follows all of the practices of the pt’s stated religion and should know that the degree of religious commitment and orthodoxy is highly variable within religious traditions Nurses often misjudge pt perceptions; nurses underestimated how much spirituality supported coping and quality of life compared to their pt’s reported estimations o Clinical Assessment Environment—any symbols present: Bible, devotional literature, cross, etc. 4 Behavior—does pt appear to pray before meals Verbalization—does pt mention God, etc. Affect and attitude—does pt appear lonely, depressed, angry, anxious, etc. Interpersonal relationship—visitors and pt’s responses to visitors Diagnosing o Spiritual Distress—impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself o Readiness for Enhanced Spiritual Well-Being—acknowledges that some people respond to adversity with increased sensitivity to spirituality or spiritual maturation o Risk for Spiritual Distress—may be appropriate for a pt who presently shows no indication of the disruption of spirit, yet may if a nurse fails to intervene Implementing o Providing Presence—just being there with the client Presence—nurse is physically present but not focused on pt Partial presence—nurse is physically present and attending to some task on the pt’s behalf but not relating to the pt on any but the most superficial level Full presence—nurse is mentally, emotionally, and physically present; intentionally focusing on the pt Transcendent presence—nurse is ^^ plus spiritually present for a pt; involves a transpersonal and transforming experience o Supporting Religious Practices Create trusting relationship with the pt so that any religious concerns or practices can be openly discussed and addressed. If unsure of pt religious needs, ask how nurses can assist in having these needs met. Avoid relying on personal assumptions. Do not discuss personal spiritual beliefs with pt unless they request. Inform pt and family caregivers about spiritual support available at your institution. Allow time and privacy for, and provide comfort measures prior to, private worship, prayer, meditation, reading or other spiritual activities. Respect and ensure safety of the pt’s religious articles. Facilitate clergy and spiritual care specialist visitation. Collaborate w/ chaplain. Prepare pt’s environment for spiritual rituals or clergy visitations. Make arrangements with dietitian so that dietary needs can be met. Acquaint yourself with the religions, spiritual practices, and cultures of the area. Remember there can be difference between facilitating/supporting a pt’s religious practice and participating in it yourself. Ask another nurse to assist you if a particular practice makes you uncomfortable. All spiritual therapeutics must be done within agency guidelines o Assisting Clients with Prayer Pt’s preferences for prayer reflect their personalities. Ask to pray in a way that allows both of you to feel comfortable. Assess who pt prays to. Before you pray, assess what they want you to pray 5 for. Listen carefully – the answer may provide greater insight into their fears and concerns. Personalize their prayer. Use prayer to summarize a conversation, letting pt know you’ve heard what they said. Follow a prayer with nonverbal communications. Remember some pts would like to pray aloud with you. Praying with pt may not involve verbalization. Schedule time for pt to pray and help with articles that accompany prayer. Encourage pt to use positively framed prayer that will benefit them most & think about what prayer means to them o Referring Clients for Spiritual Counseling Pt may deny necessary medical intervention because of religious tenants. In this case, nurse encourages pt to discuss conflict and consider alternative methods of therapy. Nurse’s major role is to provide information the pt needs to make an informed decision, and to support the pt’s decision. Specific Religions o Amish—likely won’t have insurance, rely on religious community for support o Anglicans, Episcopalians, Roman Catholics—appreciate receiving Communion, mark head with Ashes on Ash Wednesday (40 days before Easter), practice Lent o Buddhist—may be vegetarian, facilitate meditation o Christian Scientist—typically oppose Western medical interventions, relying on lay and professional Christian Science practitioners o Hindu—most eat no beef; many are vegetarians. Cleanliness highly valued. o Jehovah’s Witnesses—abstain from most blood products, need to discuss alternative treatments such as blood conservation strategies, etc. o Jews—Kosher, Sabbath o LDS, Mormon—avoid alcohol, caffeine, smoking. Wear temple undergarments o Muslim—respect modesty, avoid nakedness: provide same gender nurse. Support prayers 5X daily. No pork Children, pregnant, elderly, and sick exempt from daytime fast during month of Ramadan. o Roman Catholics—Sacrament of the Sick o Seventh-Day Adventists—avoid unnecessary treatments on Saturday (Sabbath); prefer restful, spirit-nursing family activities on Sabbaths. Vegetarians, abstain from caffeinated beverages. Don’t smoke or drink alcohol 6 Chapter 42: Stress & Coping, p. 1079 Concepts Exam 4 CONCEPT OF STRESS Stress—a condition in which the person responds to changes in the normal balanced state o Stressor—any event or stimulus that creates stress o Stress can be a good thing in that it stimulates the thinking process, it keeps on alert, and it helps with personal growth o Stress causes problems when it overwhelms coping mechanisms Sources of Stress o Developmental stressors: occur at predictable timetable throughout one’s individual life Help us form our coping measures for situational stressors o Internal stressors: originate within a person (Ex: infections or feelings of depression) o External stressors: originate outside of the body (Ex: a move to another city, a death in the family, or pressure from peers) o Situational stressors: unpredictable and may occur at any time during life – may be positive or negative Developmental Stressors—occur at predictable times throughout ones individual life o Child—beginning school, establishing peer relationship, peer competition o Adolescent—changing physique, relationships involving sexual attraction, exploring independence, choosing a career o Young adult—marriage, leaving home, managing a home, getting started in an occupation, continuing one’s education, children o Middle adult—physical changes of aging, maintaining social status and standard of living, helping teenage children to become independent, aging parents o Older adult—decreasing physical abilities and health, changes in residence, retirement and reduced income, death of spouse and friends Situational stressors—unpredictable and may occur at any time during life. o Situational stress may be positive or negative; the following are examples: Death of a family member Marriage or divorce Birth of a child New job Illness EFFECTS OF STRESS Stress can be: o Physical: stress can threaten a persons physiologic homeostasis o Emotional: stress can produce negative or nonconstructive feelings about the self o Intellectual: stress can influence a person’s perceptual and problem- solving abilities o Social: stress can alter a person’s relationships with others 1 o Spiritual: stress can challenge one’s beliefs and values Stress can cause: o Skin disorders Eczema, pruritis, urticarial, psoriasis o Respiratory disorders Asthma, hay fever, TB o Cardiovascular disorders Coronary artery disease, essential hypertension, CHF o Gastrointestinal disorders Constipation, diarrhea, duodenal ulcer, anorexia nervosa, obesity, ulcerative colitis o Menstrual irregularities o Musculoskeletal disorders Rheumatoid arthritis, low back pain, migraine headache, muscle tension o Metabolic disorders Hyperthyroidism, hypothyroidism, diabetes o Cancer o Accident proneness o Decreased immune response Stressors (external or internal)excite receptorshypothalamus anterior pituitary adrenocorticopic hormoneadrenals o Sympathetic Pathways—Catecholaminesstress response of body tissues: Elevation of cardiac output Vasomotor changes Lipolysis Glycogenolysis Insulin suppression Increased respiration o Cortical steroids inhibit stress response: Gluconeogenesis Protein catabolism Inhibition of glucose uptake Suppression of protein synthesis Stabilization of vascular reactivity Immune response suppression MODELS OF STRESS Models of stress assist nurses to identify the stressor in a particular situation and to predict the pt’s response. Use models to assist pt in strengthening healthy coping responses and in adjusting unhealthy, unproductive responses. Stimulus-Based Models o Stress is defined as a stimulus, a life event, or a set of circumstances that arouses physiologic and/or psychological reactions that may increase the individual’s vulnerability to illness 2 o Scales are used to set up and identify specific stress – it is used to document a person’s relatively recent experiences, such as divorce, pregnancy, and retirement o In this view, both positive and negative events are considered stressful Response-Based Models o This is the “nonspecific response of the body to any kind of demand made upon it” o Selye’s stress response is characterized by a chain or pattern of physiologic events called the general adaptation syndrome (GAS) or stress syndrome o General Adaptation Syndrome—Seyle used the term stressor to denote any factor that produces stress and disturbs the body’s equilibrium. Because stress is a state of the body, it can be observed only by the changes it produces in the body This response of the body syndrome or GAS, occurs with the release of certain adaptive hormones and subsequent changes in the structure and chemical composition of the body Parts of the body particularly affected by stress are the GI tract, the adrenal glands, and the lymphatic structures With prolonged stress, the adrenal glands enlarge considerably; the lymphatic structures, such as the thymus, spleen, and lymph nodes, atrophy (shrink); and deep ulcers appear in the lining of he stomach In addition to adapting globally, the body can also react locally; that is, one organ or part of the body reacts alone; this is referred to as the local adaptation syndrome (LAS). One example is inflammation Both GAS & LAS have three stages: alarm reaction, resistance, and exhaustion Alarm Reaction o This alerts the body’s defenses; divided into two parts o Shock Phase: the stressor may be perceived consciously or unconsciously by the person Stressor stimulate the sympathetic nervous system, which in turn stimulates the hypothalamushypothalamus releases corticosteroids hormone, which stimulates the anterior pituitary gland to release adrenocorticotrophic hormone During times of stress, the adrenal medulla secretes epinephrine and norepinephrine in response to sympathetic stimulation Significant body responses to epinephrine include the following: Increased myocardial contractility, which increases CO and blood flow to active muscles Bronchial dilation, which allows increased oxygen intake Increased blood clotting Increased cellular metabolism Increased fat metabolization to make energy available and to synthesize other compounds needed by the body Norepinephrine decreases blood flow to kidneys & increases secretion of renin 3 Renin is an enzyme that hydrolyzes one of the blood proteins to produce angiotensin, which tends to increase BP by constricting arterioles Sum of all adrenal hormonal effects permits person to perform far more strenuous physical activity than would otherwise be possible This person is then ready for “fight or flight”, this is the primary response and is short-lived from 1 minute to 24 hours o Countershock Phase During this time, the changes produced in the body during the shock phase are reversed, thus a person is best mobilized to react during the shock phase of the alarm reaction Resistance Stage o This is when the body’s adaptation takes place o The body attempts to cope with the stressor and to limit the stressor to the smallest area of the body that can deal with it Exhaustion Stage o The adaptation that the body made during the second stage cannot be maintained The ways used to cope with the stressor have been exhausted If adaptation has not overcome the stressor, the stress effects may spread to the entire body o At the end of this stage, the body may either rest and return to normal, or [premature] death may be the ultimate consequence o The result of this stage depends on the adaptive energy resources of the individual, the severity of the stressor, and the external adaptive resources that are provided, such as oxygen INDICATORS OF STRESS Physiologic Indicators Physiological Indicators—signs and symptoms of stress that result from activation of the sympathetic and neuroendocrine; responses vary based on the individual’s perception of events Psychological Indicators Psychological Indicators—anxiety, fear, anger, depression, and unconscious ego defense mechanisms. Some are helpful, while others are hindrance – depending on the situation and length of time they are used or experienced Anxiety—a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significance relationships. Manifested on four levels. [S/S from Table 42-2, p. 1083] o Mild Anxiety—produces slight arousal state that enhances perception, learning, and productive abilities. Most healthy people experience mild anxiety, p perhaps as a feeling of mild restlessness that prompts a person to seek information and asks questions S/S: increased questioning, mild restlessness, sleeplessness, feeling of increased arousal and alertness, uses learning to adapt o Moderate Anxiety—increases the arousal state to a point where the person expresses feelings of tension, nervousness, or concern. 4 Perpetual abilities are narrowed. Attention is focused more on a particular aspect of a situation than on peripheral activities S/S: voice tremors and pitch changes, tremors, facial twitches, and shakiness, increased muscle tension, narrowed focus of attention, able to focus but selectively inattentive, learning slightly impaired, slightly increased respiratory and HR, mild gastric symptoms (butterflies) o Severe Anxiety—consumes most of the persons’ energy and requires intervention. Perception is further decreased. The person, unable to focus on what is really happening, focuses on only one specific detail of the situation generating the anxiety. S/S: communication difficult to understand, increased motor activity, inability to relax, fearful facial expr3ession, inability to focus or concentrate, easily distracted, learning severely impaired, tachycardia, hyperventilation, headache, dizziness, and nausea o Panic—an overpowering, frightening level of anxiety causing the pt to lose control. It is less frequently experienced than other levels of anxiety. The perception of a panicked person can be affected to the degree that the person distorts events S/S: communication may not be understandable, increased motor activity, agitation, unpredictable responses, trembling, poor motor coordination, perception distorted or exaggerated, unable to learn or function, dyspnea, palpitations, choking, chest pain, or pressure, feeling of impending doom, paresthesia, sweating Fear—emotion or feeling of apprehension aroused by impending or seeming danger, pain, or another perceived threat. May be in response to something that has occurred, in response to an immediate or current threat, or in response to something that the person believes will happen Anxiety and fear differ in four ways: o The source of anxiety may not be identifiable. The source of fear is identifiable o Anxiety is related to the future – to an anticipated event. Fear is related to the present. o Anxiety is vague and fear is definite. o Anxiety is the result of psychological or emotional conflict. Fear is the result of discrete physical or psychological entity. Anger—emotional state consisting of a subjective feeling of animosity or strong displeasure o Hostility—usually marked by overt antagonism and harmful or destructive behavior o Aggression—unprovoked attack or a hostile, injurious, or destructive action or outlook o Violence—the exertion of physical force to injury or abuse Depression o An extreme feeling of sadness, despair, dejection, lack of worth, or emptiness, affects millions of Americans a year 5 o S/S: tiredness, sadness, emptiness, or numbness, irritability, inability to concentrate, hard to make decisions, loss of sexual desire, crying, sleep disturbances, and social withdrawal, loss of appetite, weight loss, constipation, headache, and dizziness Ego Defense Mechanisms: Table 42-3, p. 1085 o Unconscious psychological adaptive mechanisms or mental mechanism that develop as the personality attempts to defend itself, establish compromises among conflicting impulses, and calm inner tensions o Compensation—cover up weakness by emphasizing a more desirable trait or by overachievement in a more comfortable area o Denial—attempt to ignore unacceptable realities by refusing to acknowledge them o Displacement—transferring or discharging of emotional reactions from one object or person to another o Identification—attempt to manage anxiety by imitating the behavior of someone feared or respected o Intellectualization—an emotional response that normally would accompany an uncomfortable incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings o Introjection—a form of identification that allows for the acceptance of others’ norms and values into oneself, even when contrary to one’s previous assumptions o Minimization—not acknowledging the significance of ones’ behavior o Projection—blame is attached to others or the environment for unacceptable desires, thoughts, and mistakes o Rationalization—justification of certain behaviors by faulty logic and ascribing motives that are socially acceptable but did not in fact inspire the behavior o Reaction formation—causes people to act exactly opposite to the way they feel o Regression—resorting to an earlier level of functioning that is characteristically less demanding and responsible o Repression—unconscious mechanism by which threatening thoughts, feelings, and desires are kept from becoming conscious; the repressed material is denied entry into the consciousness o Sublimation—displacement of energy associated with more primitive sexual or aggressive drives into socially accepted activities o Substitution—the replacement of a highly values, unacceptable, or unavailable object by a less valuable, acceptable, or available object o Undoing—an action or words designed to cancel some disapproved thoughts, impulses, or acts in which the person relieves guilt by making reparation Clinical Manifestations of Stress, p. 1082 o Pupils dilate to increase visual perception when serious threats to the body arise o Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism o Heart rate and cardiac output increase to transport nutrients and by- products of metabolism more efficiently 6 o Skin is pallid because of constriction of peripheral blood vessels, an effect of NE o Sodium and water retention increase due to release of mineralocorticoids, which increases blood volume o Rate and depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation o Urinary output decreases o Mouth may be dry o Peristalsis of the intestines decreases, resulting in possible constipation and flatus o For serious threats, mental alertness improves o Muscle tension increases to prepare for rapid motor activity or defense o Blood sugar increases because of release of glucocorticoids and gluconeogenesis Cognitive Indicators Cognitive Indicators—thinking responses that include problem-solving, structuring, self-control or self-discipline, suppression, and fantasy Problem solving—involves thinking through the threatening situation, using specific steps to arrive at a solution. o Person assess the situation or problem, analyzes or defines it, chooses alternatives, carries out selected alternative, and evaluates whether the solution was successful Structuring—arrangement/manipulation of a situation so that threatening events do not occur o Can be productive in certain situations Self-Control—assuming a manner and facial expression that convey a sense of being in control or in charge; deep-breathing. When self-control prevents panic and harmful or nonproductive actions in a threatening situation. Suppression—consciously putting a thought or feeling out of mind. o Temporarily relieves stress, but does not solve the problem Fantasy—make-believe; unfulfilled wishes and desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality COPING Coping strategy (mechanism)—natural or learned way of responding to a changing environment or specific problem or situation. The cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person. Problem-focused—efforts to improve a situation by making changes or taking some action; change the problem Emotion-focused—includes thoughts and actions that relieve emotional distress; change how you feel about the problem – doesn’t fix the problem but person often feels better Long-term—constructive and realistic; change in lifestyle or using problem solving in decision making instead of anger Short-term—can reduce stress to tolerable limit temporarily but are ineffective ways to permanently deal with reality Adaptive—helps the person to deal effectively with stressful events and minimizes distress associated with them 7 Maladaptive—can result in unnecessary distress for the person and others associated with the person or stressful event o ** Stress interferes with the patients ability to meet their basic human needs Altered elimination pattern, change in appetite, altered sleep pattern, nervousness, focus on stressors distracts from focus on safety, isolation, overly dependent, fails to socialize, workaholic, draws attention to self, shows lack of control, and unable to accept reality NURSING MANAGEMENT Assessment—see Assessment Interview, p. 1087 o Subjective—pt interview and health history o Objective—physical exam – can rate stress or anxiety on a scale of 0- 10 o Exam—look for S/S and anxiety levels, could see objective signs Diagnosing: o Anxiety—vague, uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by the anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with a threat o Caregiver Role Strain—difficulty in performing the family caregiver role o Compromised Family Coping—usually supportive primary person provides insufficient, ineffective, compromised support, comfort, assistance, or encouragement that may be needed by the pt to manage or master adaptive tasks related to their health challenge o Defensive Coping—repeated projection of falsely positive self- evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard o Disabled Family Coping—behavior of significant person that disables his or her capacities and the pt’s capacities to effectively address tasks essential to either person’s adaptation to the health challenge o Ineffective Coping—inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use resources o Ineffective Denial—conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety/fear, but leading to the detriment of health o Post-Trauma Syndrome—sustained maladaptive response to a traumatic, overwhelming event o Relocation Stress Syndrome—physiological and/or psychosocial disturbances following transfer form one environment to another Planning—plan goals to decrease/resolve anxiety, increase ability to manage or cope with stressful events or circumstances, and improve role performance o Want the goals to be important to the pt and make sure they relate to how the pt is feeling and their perceived effectiveness of their coping mechanisms o Set goals to change the pt’s existing responses to the stressors Implementation 8 o Exercise—physiological benefits include improved muscle tone, increased cardiopulmonary function, and weight control. Psychological benefits include relief of tension, a feeling of well-being, and relaxation o Nutrition—avoid excess caffeine, salt, sugar, and fat, and deficiencies in vitamins and minerals; allow comfort foods if they are not contraindicated by pt’s health condition o Rest and Sleep—restores the body’s energy levels and is an essential aspect of stress management. To ensure adequate sleep, pt’s need to attain comfort and learn techniques that promote peace of mind and relaxation o Support Systems—should decrease stress but sometimes increase stress o Time Management—people who manage their time effectively usually experience less stress because they feel more in control of their circumstances. Pts who feel overwhelmed often need help to prioritize tasks and to consider whether modifications can be made to decrease role demands Pts may need to learn to develop an awareness of which requests they can meet without undue stress, which ones can be negotiated, and which ones need to be declined Time management must address both what is important to the pt and what can realistically be achieved o Minimizing Anxiety Listen attentively, try to understand the pt’s perspective on the situation Provide an atmosphere of warmth and trust, convey a sense of caring and empathy Determine if it is appropriate to encourage pt’s participation in the plan of care; give them choices about some aspects of care but do not overwhelm them with the cho
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