Obese patients typically have more complications that affect various body systems. Here are some of the more common complications along with their pathophysiology and related nursing interventions.
System
Pathophysiologic consequences
Pathophysiologic problems
Nursing interven- tions
Pulmonary ● Decreased
diaphragmatic excursion
● Decreased vital capacity
● Decreased alveolar ventilation
● Decreased compliance
● Decreased respiratory drive
● Chronic carbon dioxide retention
● Increased respiratory rate
● Ventilation-perfusion mismatch
● Hypoxemia
● Respiratory acidosis
● Diffi culty weaning from the ventilator
● Obstructive sleep apnea
● Increased risk of aspiration
● Try noninvasive positive-pressure ventilation, such as bilevel positive airway pressure or continuous positive airway pressure.
● Be prepared for intubation.
● Calculate tidal volume based on ideal weight, not actual weight.
● Minimize time the patient spends in a supine position.
● Control secretions to maintain airway patency.
● Reposition at least every 2 hours.
Cardiovascular ● Left ventricular hypertrophy
● Increased total blood volume
● Increased stroke volume
● Increased cardiac output
● Increased cardiac deconditioning
● Right-sided and left- sided heart failure
● Hypertension
● Myocardial infarction
● Stroke
● Chronic venous insuffi ciency
● Deep vein thrombosis
● Pulmonary embolism
● Encourage mobility as tolerated.
● Watch for signs of fl uid overload.
● Monitor blood pressure.
● Administer
medications as ordered.
Endocrine ● Increased metabolic
requirements
● Increased insulin resistance
● Type 2 diabetes
● Hyperlipidemia
● Carefully monitor blood glucose levels, especially if the patient is receiving a steroid.
● Work with a dietitian to ensure that metabolic needs are met.
GI ● Increased intra-
abdominal pressure
● Increased gastric volume
● Increased incidence of gastroesophageal refl ux disease
● Increased risk of aspiration, especially with enteral feedings
● Increased constipation
● Increased risk of pancreatitis
● Administer
medications as ordered.
● Keep head of bed at 30 degrees when possible.
● Increase fl uid and fi ber intake.
● Monitor amylase and lipase levels.
● Be alert for altered pharmacokinetics for some drugs.
Substance abuse, dependence, and addiction ❍ 89
❖ Substance abuse, dependence, and addiction
General information◆Substance abuse is the repeated use of a drug that doesn’t result in addiction or lead to withdrawal when discontinued
◆Substance dependence is the compulsive use of a drug that results in tolerance to the drug’s effects and withdrawal symptoms when the drug is terminated or decreased
◆Addiction is characterized by loss of control of substance consumption, substance use despite associ- ated problems, and the tendency to relapse
◆Psychodynamic factors associated with addiction include lack of tolerance for frustration and pain, lack of success in life, lack of affectionate and meaningful relationships, low self-esteem and lack of self- regard, and a risk-taking propensity
◆When taking care of patients with substance abuse disorders, the nurse should be kind, warm, and supportive to help dispel the patient’s anxiety and provide a sense of security
◆The nursing process for patients with substance abuse disorders includes a thorough physical and psychosocial assessment, with emphasis on the history of drug use
◆The nurse should document patient’s drug of choice, the length of use, and the last use, both to antici pate the patient’s risk of developing withdrawal symptoms and to avoid drug interactions Alcohol abuse
◆Alcohol is the most commonly abused substance; alcoholism is more common in men, young people, whites, and those who are unmarried
◆Alcohol can affect all organ systems, particularly the central nervous system (CNS) and the GI system
◆GI problems associated with alcoholism include esophagitis, gastritis, pancreatitis, alcoholic hepatitis, and liver cirrhosis
◆Long-term use is commonly associated with tuberculosis, all types of accidents, suicide, and homicide
◆The early signs of alcohol withdrawal occur within a few hours after the last intake and peak in 24 to 48 hours; withdrawal can progress to alcohol withdrawal delirium
◆Signs and symptoms of alcohol withdrawal include hyperalertness, jerky movements, and irritability System
Pathophysiologic consequences
Pathophysiologic problems
Nursing interventions
Immune ● Impaired immune
response
● Impaired cell- mediated immunity
● Impaired healing
● Increased risk of wound infections
● Increased skin breakdown and pressure ulcers
● Decreased resistance to infection
● Monitor wounds for early signs of infection.
● Reposition the patient at least every 2 hours.
● Monitor skin folds for pressure ulcers or skin breakdown.
● Work with a dietitian to ensure that metabolic needs are met for proper healing.
Musculoskeletal ● Increased joint trauma
● Decreased mobility
● Increased atrophy from lack of use
● Increased pain with movement
● Osteoarthritis
● Rheumatoid arthritis
● Encourage mobilization.
● Perform range-of- motion exercises with the patient.
● Provide
nonpharmacologic pain- relief measures.
Complications of obesity (continued)
◆Alcohol withdrawal delirium usually peaks within 2 to 3 days and is always considered a medical emergency
◗ Signs and symptoms of alcohol withdrawal delirium include autonomic hyperactivity, severe disturbance in sensorium, perceptual disturbance, fl uctuating LOC, delusions, agitated behaviors, and fever
Substance abuse
◆Commonly abused CNS stimulants include cocaine and amphetamines
◗ Intoxication with CNS stimulants typically causes tachycardia, dilated pupils, increased blood pressure, nausea and vomiting, and insomnia
◗ Overdose with CNS stimulants can cause respiratory distress, ataxia, hyperpyrexia, convulsions, coma, stroke, MI, and death
◗ Signs and symptoms of withdrawal include fatigues, depression, agitation, apathy, anxiety, sleepi- ness, disorientation, lethargy, and craving
◆Treatment for individuals with substance abuse includes an assessment phase, treatment of the intoxication and withdrawal when necessary, and the development and implementation of an overall treatment strategy
◆Treatment should include an both an interdisciplinary care team and family members; the patient and family should also as receive referrals to support groups
❖ Pain
General information
◆Pain is a complex phenomenon that involves biological, psychological, cultural, and social factors; it’s a primarily subjective experience
◆Margo McCaffery, a pain researcher, defi nes pain as “whatever the experiencing person says it is, existing whenever the experiencing person says it does”
◆The International Association on Pain defi nes pain as unpleasant sensory and emotional experiences related to actual or potential tissue damage
Pain theories
◆All current pain-control theories are hypothetical; none completely explain the pain experience and all its components
◆The specifi city theory holds that highly specifi c structures and pathways exist for pain transmission;
this biologically oriented theory doesn’t explain pain tolerance and ignores social, cultural, and empiri- cal factors that infl uence pain
◆The pattern theory holds that rapid and slow conduction pathways exist, which relay pain information through the spinal cord to the brain; although this theory addresses the brain’s ability to determine the amount, intensity, and type of sensory input, it doesn’t address nonbiological infl uences on pain per- ception and transmission
◆The gate control theory describes a hypothetical gate mechanism in the spinal cord that allows nerve fi bers to receive pain sensations; the gate can be closed to pain sensation by occupying the receptor sites with other stimuli
◗ This theory has encouraged a holistic approach to pain control and research by considering non- biological components of pain
◗ Pain management techniques, such as cutaneous stimulation, distraction, and acupuncture, are partly based on this theory
Anatomic and physiologic basis of pain
◆Stimulation of pain receptors in skin and soft tissues typically causes defi ned, localized pain
◆Stimulation of pain receptors in deep tissues causes dull, poorly localized pain
◆Stimulation of pain receptors in the viscera or organs causes diffuse, sometimes referred pain
◆Pain can be stimulated by mechanical sources such as sharp objects; thermal sources such as fi re; or chemical sources, such as stomach acids and battery acid
◆Pain travels from the periphery to the spinal cord to the brain by way of a pathway composed of A (delta) fi bers (intense pain) and C fi bers (dull, aching pain)
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Pain assessment ❍ 91
◆Pain is processed in the thalamus, midbrain, and cortex
◆Certain neurotransmitters, such as histamine, serotonin, and prostaglandins, enhance pain impulse transmission
◆Other neurotransmitters, such as endogenous opiates, endorphins, and enkephalins, inhibit pain impulse transmission; chronic pain syndrome may be related to a defi ciency of these inhibitory neurotransmitters Factors that affect pain response
◆Pain is primarily a physical problem that has psychological effects
◆The physical and psychological sources of pain are often complex and intertwined, with causative factors diffi cult to isolate
◆Psychogenic pain is pain without a physiologic basis; this term isn’t helpful because all physical causes of pain can’t be diagnosed, and all pain is real to the patient
◆Pain threshold is the point at which a patient experiences pain
◆Pain tolerance is affected by individual, psychosocial, cultural, religious, and environmental factors; it infl uences pain duration and intensity
❖ Pain assessment
General information◆Pain can be assessed with a subjective pain assessment tool
◗ 0 to 10 rating scale: The patient is asked to rate pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable
◗ Face rating scale: The patient is shown illustrations of fi ve or more faces demonstrating varying levels of emotion, from happy to sad; by selecting the face that most closely approximates the pain sensation, the patient helps the nurse gauge the effectiveness of interventions
◗ Visual analog scale: The patient places a mark on the scale, ranging from no pain to pain as bad as it can be, to indicate his current level of pain
◗ Body diagram: The patient draws the location and radiation of pain on a paper illustration of the body
◗ Questionnaire: The patient answers questions about the pain’s location, intensity, quality, onset, and relieving and aggravating factors
◗ Pain fl ow chart: The nurse documents variations in pain, vital signs, and LOC in response to treat- ments; these forms are particularly useful for monitoring patient response to epidural opioid infu- sions and for titrating dosages
◆Pain also can be assessed by observing for objective signs, such as facial grimacing; elevated blood pressure and increased pulse and respiratory rates; muscle tension; restlessness or an inability to concentrate; decreased interest in surroundings and increased focus on pain; perspiration and pallor;
crying, moaning, or verbalizations of pain; and guarding the painful body part Pain classifi cation
◆Acute pain is mild to severe pain that’s rapid in onset and lasts less than 6 months; it can be intermit- tent or recurrent as in migraine and sinus headaches and gallbladder colic
◆Chronic pain lasts beyond the expected healing time and may be diffi cult to relate to the original injury or tissue damage; it can be further classifi ed as chronic benign pain (as in lower back pain), chronic cancer pain, or pain with ongoing peripheral pathology
Pharmacologic management of pain
◆Nonopioid drugs, such as nonsteroidal anti-infl ammatory drugs (NSAIDs) and acetaminophen, are used to treat acute pain caused by infl ammation or tissue destruction and mild to moderate pain;
they’re useful adjuncts to opioid analgesics for controlling severe, acute pain
◆Opioid analgesics such as narcotic agonist-antagonists relieve pain by occupying opioid receptor sites in the brain and spinal cord; they’re used to treat moderate to severe acute pain (postoperative pain and fractures), recurrent acute pain (sickle cell crisis, angina, and renal colic), prolonged time- limited pain (cancer and burns), and pain that requires rapid, short-term relief (procedures such as bone marrow biopsy and thoracentesis)
◆Sometimes small doses of antidepressants are used as adjuncts to pain control; they affect pain per- ception and reduce the accompanying anxiety
◆The oral route of administration is the least expensive, easiest for patients to manage, and most widely accepted by patients; most NSAIDs and some opioids can be administered orally
◆Parenteral routes (subcutaneous [Subcut], I.M., and I.V.) are widely used to administer opioids
◆Intraspinal (epidural) routes are used for short-term acute pain, such as that caused by abdominal surgery; the opioid’s systemic effect is reduced with the intraspinal route compared with other paren- teral routes
◆Topical patches, such as those containing fentanyl, are useful during the transition from epidural to oral opioids
◆Rectal administration of opioids may be indicated when a patient can’t tolerate oral medications temporarily because of nausea and vomiting
◆Patient-controlled analgesia is the I.V., Subcut, or intraspinal administration of opioids by means of an electronic controller that’s programmed to respond with small doses when the patient requests medication
◆Scheduled dosing is preferred to “as needed”; around-the-clock dosing controls pain by avoiding the major peaks and valleys of the pain experience
Nonpharmacologic management of pain
◆Cutaneous stimulation is a low-risk, inexpensive, noninvasive, readily available pain management technique that requires little skill to implement; examples include heat application, cold application, massage, pressure, vibration, and transcutaneous electrical nerve stimulation (the application of electric current through skin patches connected to a portable electrical source)
◆Therapeutic touch unblocks congested areas of energy in the body; in this technique, the practitioner redirects energy by using touch to promote comfort, relaxation, healing, and a sense of well-being
◆Acupuncture is the use of needles of various sizes to stimulate parts of the body to produce analgesia;
this centuries-old technique originated in China and is gaining acceptance in Western medicine
◆Cognitive and behavioral pain management uses imagery, distraction, relaxation techniques, and humor to help patients manage pain
◆Biofeedback teaches patients to control involuntary body mechanisms, such as heart rate, muscle spasms, and circulation
Surgical management of pain
◆Surgery seldom is used as a primary treatment for pain but can be considered to manage pain when pharmacalogic therapies fail
◆Nerve blocks involve the injection of phenol or alcohol to destroy nerve endings in a specifi c area
◆Rhizotomy is the surgical destruction of sensory nerve roots where they enter the spinal cord;
chordotomy is the transection of spinal cord nerves at the spinal cord’s midline portion
◆Neurectomy is the resection or partial or total excision of a spinal or cranial nerve
◆Cryoanalgesia deactivates a nerve using a cooled probe that causes temporary nerve injury
◆Radio-frequency lesioning may affect the nerve from the heat generated, the magnetic fi eld created by the radio waves, or both
◆Percutaneous electrical nerve stimulation uses implanted leads and a surface stimulator or implanted generator to block pain impulses by delivering electric charges to a nerve root
◆Spinal nerve blocks, rhizotomy, and chordotomy can impair bladder, bowel, and sexual functioning Nursing care of the patient in pain
◆Assess the pain’s location, and ask the patient to rate the pain using a pain scale
◆Ask the patient to describe the pain’s quality and pattern, including any precipitating or relieving factors
◆Monitor vital signs and note subjective responses to pain, such as facial grimacing and guarding of a body part
◆Administer pain medication around the clock as ordered
◆Provide comfort measures, such as back massage, positioning, linen changes, and oral or skin care
◆Teach the patient noninvasive techniques to control pain, such as relaxation, guided imagery, distrac- tion, and cutaneous stimulation
◆Teach the importance of taking prescribed analgesics before the pain becomes severe
◆Instruct the patient on the need for adequate rest periods and sleep
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Review questions ❍ 93
Referral to a pain clinic or hospice
◆Patients with chronic benign pain that can’t be controlled by nonpharmacologic interventions may benefi t from treatment at a pain clinic
◆The clinic’s interdisciplinary staff works with the patient to assess the pain and develops a pain- control regimen that helps the patient regain or maintain an acceptable level of functioning
◆Hospice programs give care and support to dying patients and their families; pain control—one of the primary goals—provides the patient with adequate pain relief at home
Review questions
1. The nurse is teaching a group of patient care attendants about infectioncontrol measures. The nurse tells the group that the fi rst line of intervention for preventing the spread of infection is:
A. wearing gloves.
B. administering antibiotics.
C. hand hygiene.
D. assigning private rooms for patients.
Correct answer: C Hand hygiene is the fi rst line of intervention for preventing the spread of infec- tion. Option B is incorrect because antibiotics should be initiated only when an organism is identifi ed.
Although wearing gloves (Option A) and assigning private rooms (Option D) can also decrease the spread of infection, they should be implemented according to standard precautions when indicated.
2. The nurse is caring for a patient who was given pain medication before leaving the recovery room. Upon returning to his room, the patient states that he is still experiencing pain and requests more pain medication. Of the following actions, which is the fi rst for the nurse to take?
A. Tell the patient that he must wait 4 hours for more pain medication.
B. Give half of the ordered as-needed dose.
C. Document the patient’s pain.
D. Notify the practitioner that the patient is still experiencing pain.
Correct answer: D The practitioner should be notifi ed that the patient is still experiencing pain so that new medication orders can be established. Option A is incorrect because patients who have recently undergone surgery shouldn’t have to wait 4 hours for pain relief. Option B is incorrect because a nurse can’t alter a dose without fi rst consulting the practitioner; doing so could result in a nurse being charged with practicing medicine without a license. Although the nurse should document the patient’s pain, Option C, it isn’t the fi rst action the nurse should take.
3. A patient is admitted to the health care facility with a possible electrolyte imbalance. The patient is disori- ented and weak, has an irregular pulse, and takes hydrochlorothiazide. The patient most likely suffers from:
A. hypernatremia.
B. hyponatremia.
C. hyperkalemia.
D. hypokalemia.
Correct answer: D Signs and symptoms of hypokalemia include GI, cardiac, renal, respiratory, and neurologic symptoms. Options A, B, and C are incorrect because the use of a potassium-wasting diuretic, such as hydrochlorothiazide, without potassium supplement therapy causes hypokalemia.
4. The nurse is assessing a patient who may be in the early stages of dehydration. Early signs and symptoms of dehydration include:
A. coma and seizures.
B. sunken eyeballs and poor skin turgor.
C. increased heart rate with hypotension.
D. thirst and confusion.
Correct answer: D Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Options A, B, and C are incorrect because coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs and symptoms of dehydration.
5. The nurse is evaluating a postoperative patient for infection. Which sign or symptom would be most indicative of infection?
A. Presence of an indwelling urinary catheter B. Rectal temperature of 100° F (37.8° C)
C. Redness, warmth, and tenderness at the incision site D. WBC count of 8,000/mL
Correct answer: C Redness, warmth, and tenderness at the incision site would lead the nurse to suspect a postoperative infection. Option A is incorrect because the presence of an invasive device predisposes a patient to infection but alone doesn’t indicate infection. Option B is incorrect because a rectal temperature of 100° F is a normal fi nding in a postoperative patient because of the infl ammatory response. Option D is incorrect because a normal WBC count ranges from 4,000 to 10,000/mL.
6. When planning the postoperative care of a patient who underwent surgery for repair of a lacerated spleen after an alcohol-related motor vehicle accident, what intervention should take priority in the immediate post- operative period?
A. Monitoring the patient for signs and symptoms of alcohol withdrawal B. Encouraging early ambulation
C. Splinting the abdomen for coughing and deep-breathing exercise D. Monitoring the patient’s renal function
Correct answer: A The nurse’s priority should be monitoring the patient for signs and symptoms of alcohol withdrawal because alcohol withdrawal usually manifests several hours after the last intake of alcohol. Early recognition of withdrawal symptoms helps prevent progression into alcohol withdrawal delirium. Although encouraging early ambulation (Option B), splinting the abdomen (Option C), and monitoring the patient’s renal function (Option D) are important nursing interventions, they don’t take priority in the immediate postoperative period.
7. Which diet would be most appropriate for a patient with ulcerative colitis?
A. A low-fat diet B. A low-residue diet C. A high-calorie diet D. A high-fi ber diet
Correct answer B A low-residue diet is used to avoid GI tract irritation and decrease fecal volume, appropriate measures for a patient with ulcerative colitis. Such a patient doesn’t need to follow a low- fat diet (Option A) or to consume additional calories (Option C). A patient with ulcerative colitis should avoid a high-fi ber diet (Option D), which contains such foods as whole grain cereals and fruit.
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