A 45 year old male comes in from the ER with complaints of abdominal pain that started yesterday morning. He also complains of frequent dark tarry stool that has lasted for 3 days and coffee ground looking emesis that just started yesterday. He states he feels dizzy and very weak. The pt looks pale and diaphoretic. His mucous membranes are dry. Current vital signs are: Temp 98.8, BP 99/62, HR 111, O2 Sat 98% and pain rating of 8 on 1-10 scale. Patients medications include Aspirin 325 mg PO daily, Lisinopril 2.5 mg PO Daily, Liptior 10 mg PO at bedtime, and Coumadin 5 mg Daily. Lab work shows the following: Hgb 7.4, Hct 35%, INR 6.7.

Fluid Volume Deficit related to hemorrhage as evidence by dry mucous membranes, BP 99/62, HR 111, Hgb 7.4, coffee ground looking emesis, abdominal pain, INR 6.7, and frequent dark tarry stools.

SUBJECTIVE DATA:

Abdominal pain that started yesterday morning, , frequent dark tarry stools that has lasted for 3 days, coffee ground looking emesis that started yesterday, feels dizzy and very weak.

OBJECTIVE DATA:

Pt looks pale, diaphoretic, mucous membranes are dry, VS BP 99/62, HR 111,  pain rating of 8 on 1-10 scale, Hgb 7.4, INR 6.7.

1. Pt’s HGB will be greater or equal to 14 as evidence by lab values within 48 hours.
2. Pt’s input will be equal to output as evidence by shift I & O reports within 72 hours.
3. Pt’s mucous membranes will appear moist as evidence nursing documentation within 48 hours

Potential Nursing Interventions:

1. Pt will be transfused 2 units of Packed Red Blood Cells per MD order and HGB will be rechecked 1 hour after transfusion has completed.
2. Nursing will measure and accurately record patients input and output hourly.
3. Pt will be started on Normal Saline IV at 150 cc/hr  for 24 hours per MD order and mucous membranes will be reassessed within 24 hours

Stress is high!

Start with deep breathing!

The first thing you need to do is get your anxiety under control.

Think about all the ways you know you relax and develop a plan for managing your anxiety while you study and during your test!

This is step 1 and it is foundational to doing well!

Week 4 Group Discussion Activity (5%)

The goal of this activity is to work together with your assigned group and conclude how you would react to or resolve the problem or question asked in your case study.

**If any students do not participate with their group fairly, please do not include their name at the top of your submission.  Students who do not appropriately participate will receive a grade of 0.

For this discussion activity, please practice using APA citations, both in-text and at the end of your document; it is always helpful to use references, whether they are online or hardcopy.  You must not plagiarise, which means you must use your own words and cite if you include the thoughts of someone else (websites, books, etc.).  Marks will be deducted if you do not cite correctly. We must take referencing seriously!  I encourage you to find scholarly resources; however, it is not mandatory at this time.

In terms of length, your response should be no longer than 1 page double spaced.

How to submit:
Please upload your document under Assignment --> Current Issues Discussion --> Week 4.  You will be allowed up to 2 chances to upload in case of any errors.

Please have one student in the group submit ONE copy of your group's response.  You can do so via My Group. All group members will actively participate will receive the same mark.

At the top of your submission, please include:

• Names and student IDs
• Group number
• Question asked

Week 4 Breakout Group Questions

You are working in the emergency department (ED) of a community hospital when the ambulance arrives with Annie, a 28-year-old woman who was involved in a house fire. She was sleeping when the fire started.  She managed to make her way out of the house through thick smoke. The EMS Advanced Paramedic crew started 100% humidified oxygen at 15 L/min per non-rebreather mask and started a 16-gauge IV with lactated Ringer’s solution. On arrival in the ED, her vital signs are 100/66, 125, 34, SpO2 93%. She is alert and oriented x 4 and appears anxious and in pain.

Your first step is to obtain a report from the EMS Crew and begin your initial emergency assessment.

INITIAL EMERGENCY ASSESSMENT

• Obtain the history of the injury and confirm all prehospital interventions.
• Follow ABC (Airway, Breathing, Circulation) to ensure patient remains alive in the immediacy.
• Your first action is to evaluate patency of her airway and continue 100% humidified oxygen therapy at 15 L through a non-rebreather mask.
• Have equipment readily available for endotracheal intubation or tracheostomy.
• Start pulse oximetry and continuous ECG monitoring.
• Insert a second large-bore (18 gauge or larger) IV line and begin fluid replacement.
• Perform cardiovascular and peripheral vascular and neurologic assessments.
• Obtain baseline CBC, CMP, ABGs, carboxyhemoglobin levels and weight.
• Give analgesia.
• Elevate burned limbs above the heart.
• Remove non-adherent clothing
• Assess the extent and nature of burns
• Cover burned areas with dry dressings or clean sheet
• Insert an indwelling catheter and nasogastric tube as ordered by the emergency room NP who has joined you during your initial assessment.
• Offer psychological support to Alma and her family.

YOU ARE CONCERNED ABOUT SMOKE INHALATION AND PERFORM A SECONDARY ASSESSMENT AFTER ENSURING YOUR PATIENT IS STABLE

• Assess for burns to the face and neck; singed nasal or facial hair; and cherry-red skin color.
• Cough with or without copious sputum that may or may not be black, gray, carbonaceous, or bloody; smoky breath.
• Inspect the oropharynx and vocal cords for redness, ulcerations, swelling, and blisters.
• Observe Alma for increasing restlessness, dyspnea, difficulty swallowing, increasing hoarseness, stridor, wheezing, and nasal flaring.
• Monitor VS for tachycardia, dysrhythmias, a decrease in oxygen saturation, and rapid, shallow respirations.
• Monitor ABGs and carboxyhemoglobin levels.
• Monitor for neurological changes associated with hypoxia such as restlessness, anxiety, altered mental status, confusion, decreased level of consciousness.

 As you perform your initial assessment, you note burns on Alma's right anterior leg, left anterior and posterior leg, and anterior torso. You know you will need to document this using the rule of nines - calculating the extent of Alma's burn injury.

Continued Assessment...

During the initial period of a burn injury, the Hgb and Hct levels increase to above normal because of hemoconcentration from the large fluid shifts and resulting vascular dehydration. Hct levels of 50% to 55% are expected during the first 24 hours after injury, which will return to normal by 36 hours after injury. Na and Cl levels are low because of fluid loss associated with the burn injury and sodium retention in the interstitial spaces. BUN is slightly elevated because of fluid loss. Hyperglycemia occurs during the acute phase because of lipolysis, gluconeogenesis, glycogenolysis, and relative insulin insensitivity.

When we are looking at "Nursing Diagnosis" what we are really looking for is......

What do I need to DO to help my patient...and within that list of things to do which ones should I do FIRST.

Looking at Alma's case: when you look at all of your assessment data what are your priority actions?

1. Maintain Patent Airway
2. Restore fluid and electrolyte status (Fluid Resuscitation)
3. Pain Control
4. Provide Emotional Support to client and clients support system
5. Wound and Skin Integrity
6. Infection Prevention

Out of those 5 priorities, you will need to continuously assess which one to do first, second, third...and then when to repeat. 

For example: If the patient's airway suddenly becomes unstable, you would not continue with wound care while your patient stops breathing.

Note: Every intervention comes from a best practice. Best practice comes from evidence....evidence is derived from research! So this is where you need to have evidence to support your choice of intervention.  Interventions also have to be evaluated as to whether you can INITIATE the intervention without an order from the NP/MD or if there is a standing order, or if you need to seek an order before intervening.

Interventions always need to be SMART!!

Remember- They need to be Specific to your intervention, you need to be able to Measure them either quantitatively or qualitatively, they need to be Achievable meaning it is something that you have the resources for and that your client could do (you can't say you will teach a snail to fly...they don't have wings), Relevant meaning it is directly related to your priority need/diagnosis and Timely- This one is VERY important - If your intervention is for an emergent need your timeline needs to reflect that urgency (example: acute pain - you should not be waiting more than 15-20 mins to re-evaluate the effectiveness of pain control when given through IV - 30 min-45 mins for PO pain meds)!

Looking at our priorities above:

1. Patent Airway - The intervention for nurses is to maintain observation and continued assessment of the patient's respiratory status (How?). Do we need an order? Where could you find this as your best practice?

2. Restore fluid and electrolyte status (Fluid Resuscitation) - This intervention requires nurses to administer fluids to replace the loss as well as encourage fluid to navigate back into the cell from outside the cell. What kind of fluid would that be? Do you need an order to administer fluids? Why? Where could you find the evidence of fluid resuscitation and what kind of fluid needed to support your conversation with a NP/MD?

3. Pain Control - This intervention requires nurses to administer either or both pharmacological intervention and/or complimentary therapies. Thinking about this...what is Alma's pain like? How do you know? What would you offer for pain control? why? Do you need an order? Where could you find this evidence to support the best practice? 

4. Provide Emotional Support to client and clients support system - What does this intervention look like? What can you offer the client or their support to help them? Do you need an order? Where is the evidence for this intervention?

5. Wound and Skin Integrity - What did the Rule of 9's tell you about her wounds? What do we do for new burns? Do you need an order? Where is the evidence to support this?

6. Infection Prevention - Open wounds and fresh burns - what about a burn makes it specifically more challenging to handle than a regular surgical wound or abrasion? What can we do to help? Standard interventions such as: Place her in a private room and initiate protective isolation procedures. Use aseptic technique with sterile gloves during dressing changes. All supplies necessary for patient should remain in her room. No one with an actual or potential infection should care for or visit her. Provide family education about infection precautions. Administer antibiotics and antipyretics as prescribed. Change bed linens daily and whenever soiled. She would receive a tetanus toxoid because of the chance of anaerobic burn wound contamination. HOW do we know this is best practice? Do we need an order for any of these? Where can we find the evidence to support this?

Evaluations always need to re-evaluate your SMART interventions using the criteria you established

Remember- They need to be Specific to your intervention, you need to be able to Measure them either quantitatively or qualitatively, they need to be Achievable meaning it is something that you have the resources for and that your client could do (you can't say you will teach a snail to fly...they don't have wings), Relevant meaning it is directly related to your priority need/diagnosis and Timely- This one is VERY important - If your intervention is for an emergent need your timeline needs to reflect that urgency (example: acute pain - you should not be waiting more than 15-20 mins to re-evaluate the effectiveness of pain control when given through IV - 30 min-45 mins for PO pain meds)!

1. Patent Airway - The intervention for nurses is to maintain observation and continued assessment of the patient's respiratory status

• EVALUATION: 

2. Restore fluid and electrolyte status (Fluid Resuscitation) - This intervention requires nurses to administer fluids to replace the loss as well as encourage fluid to navigate back into the cell from outside the cell. What kind of fluid would that be? Do you need an order to administer fluids? Why? Where could you find the evidence of fluid resuscitation and what kind of fluid needed to support your conversation with a NP/MD?

3. Pain Control - This intervention requires nurses to administer either or both pharmacological intervention and/or complimentary therapies. Thinking about this...what is Alma's pain like? How do you know? What would you offer for pain control? why? Do you need an order? Where could you find this evidence to support the best practice? 

4. Provide Emotional Support to client and clients support system - What does this intervention look like? What can you offer the client or their support to help them? Do you need an order? Where is the evidence for this intervention?

5. Wound and Skin Integrity - What did the Rule of 9's tell you about her wounds? What do we do for new burns? Do you need an order? Where is the evidence to support this?

6. Infection Prevention - Open wounds and fresh burns - what about a burn makes it specifically more challenging to handle than a regular surgical wound or abrasion? What can we do to help? Standard interventions such as: Place her in a private room and initiate protective isolation procedures. Use aseptic technique with sterile gloves during dressing changes. All supplies necessary for patient should remain in her room. No one with an actual or potential infection should care for or visit her. Provide family education about infection precautions. Administer antibiotics and antipyretics as prescribed. Change bed linens daily and whenever soiled. She would receive a tetanus toxoid because of the chance of anaerobic burn wound contamination. HOW do we know this is best practice? Do we need an order for any of these? Where can we find the evidence to support this?

Four days after her injury, Alma is discharged from your medical unit and is admited to the rehabilitation floor where she begins a formal rehabilitation program and is able to maintain full range of motion and tissue mobility. Her recovery is prolonged by two wound infections, and she does experience some scarring.

One year later she is still struggling with adapting to her new body image, but she is finding encouragement from family, friends, and her support group.

Week 4 Application Assignment

Pain is a complex, multidimensional phenomenon that is one of the greatest challenges to nurses in providing quality care to patients. Nurses are responsible for pain assessment and for the evaluation of the effects of pain therapies. This requires nurses to know the different types of pain, methods of data collection, and measurement of the components of the pain experience. Nursing’s role in the management of the patient with pain is important in both pharmacological and nonpharmacological pain therapies. It is important to examine the common barriers to pain management, ethical issues related to pain management, and pain management in special populations. The role of the nurse is also as a member of multiprofessional teams that provide comprehensive, multimodal pain management with patients.

Culture & Pain

How can culture affect pain? 

"Pain is a universal human experience that affects people across their lifespan. The mechanisms of perceiving and responding to pain differ among individuals and are affected by multiple interrelated biological, psychological, and social factors (Gatchel, McGreary, McGeary & Lippe 2014). Cultural and ethnic backgrounds appear to further influence how individuals perceive, manifest, and handle pain. For instance, in a study by Aufiero, Stankewicz, Quazi, Jacoby and Stoltzfus (2017), a standardized pain stimulus was administered to two groups of Caucasian and Latino adult patients from both genders. Results indicate a significant difference in pain rating between the groups, with Latinos and women reporting higher levels of pain. In another study, Herbert et al. (2017) investigated cultural pain differences among a sample of African American and non-Hispanic White individuals diagnosed with osteoarthritis. Their findings revealed an association between ethnic identity and cortisol levels that were negatively correlated with the intensity of reported pain. Similarly, a Robertson, Robinson, and Stephens’ Study (2017) indicated that Japanese participants rate their level of pain significantly higher than British participants. Despite this growing evidence, the literature pertaining to how culture influences pain presentation continues to need additional investigation. For instance, Ostrom et al. (2017) argue that differences in pain tolerance are not that simple and are linked to emotional, psychosocial, cognitive and other factors which exert a greater influence on perception of pain compared to race and culture"(Miller & Abu-Alhaija, 2019, p.183).

Miller, E., & Abu-Alhaija, D. (2019). Cultural Influences on Pain Perception and Management [Abstract]. Pain Management Nursing, 20(3), 183-184.

https://www.camh.ca/en/health-info/guides-and-publications/medication-use-in-older-adults#:~:text=Although%20adults%20aged%2065%20and,one%20medication%20at%20a%20time.

https://www.cps.ca/en/documents/position/pharmacare

https://www.cps.ca/en/documents/position/improving-paediatric-medications

In this section, you will:

• Determine whether a relation represents a function.
• Find the value of a function.
• Determine whether a function is one-to-one.
• Use the vertical line test to identify functions.
• Graph the functions listed in the library of functions.

A jetliner changes altitude as its distance from the starting point of a flight increases. The weight of a growing child increases with time. In each case, one quantity depends on another. There is a relationship between the two quantities that we can describe, analyze, and use to make predictions. In this section, we will analyze such relationships.

A relation is a set of ordered pairs. The set consisting of the first components of each ordered pair is called the domain and the set consisting of the second components of each ordered pair is called the range. Consider the following set of ordered pairs. The first numbers in each pair are the first five natural numbers. The second number in each pair is twice that of the first.

$$\{(1,\text{ }2),\text{ }(2,\text{ }4),\text{ }(3,\text{ }6),\text{ }(4,\text{ }8),\text{ }(5,\text{ }10)\}$$

The domain is \(\{1,\text{ }2,\text{ }3,\text{ }4,\text{ }5\}\). The range is \(\{2,\text{ }4,\text{ }6,\text{ }8,\text{ }10\}\).

Note that each value in the domain is also known as an input value, or independent variable, and is often labeled with the lowercase letter \(x\). Each value in the range is also known as an output value, or dependent variable, and is often labeled lowercase letter \(y\).

A function \(f\) is a relation that assigns a single value in the range to each value in the domain. In other words, no x-values are repeated. For our example that relates the first five natural numbers to numbers double their values, this relation is a function because each element in the domain, \(\{1, 2, 3, 4, 5\}\), is paired with exactly one element in the range, \(\{2, 4, 6, 8, 10\}\).

Now let’s consider the set of ordered pairs that relates the terms “even” and “odd” to the first five natural numbers. It would appear as

$$\{{(\text{odd},\text{ }1),\text{ }(\text{even},\text{ }2),\text{ }(\text{odd},\text{ }3),\text{ }(\text{even},\text{ }4),\text{ }(\text{odd},\text{ }5)}\}$$

Notice that each element in the domain, \(\{even, odd\}\) is not paired with exactly one element in the range, \(\{1, 2, 3, 4, 5\}\). For example, the term “odd” corresponds to three values from the range, \(\{1, 3, 5\}\) and the term “even” corresponds to two values from the range, \(\{2, 4\}\). This violates the definition of a function, so this relation is not a function.

Figure 1 compares relations that are functions and not functions.

A function is a relation in which each possible input value leads to exactly one output value. We say “the output is a function of the input.”

The input values make up the domain, and the output values make up the range.

Examples

Given a relationship between two quantities, determine whether the relationship is a function.

Once we determine that a relationship is a function, we need to display and define the functional relationships so that we can understand and use them, and sometimes also so that we can program them into computers. There are various ways of representing functions. A standard function notation is one representation that facilitates working with functions.

To represent “height is a function of age,” we start by identifying the descriptive variables \(h\) for height and \(a\) for age. The letters \(f\), \(g\), and \(h\) are often used to represent functions just as we use \(x, y\), and \(z\) to represent numbers and \(A, B\), and \(C\) to represent sets.

$$ \begin{array}{lcccc}h\text{ is }f\text{ of }a&&&&\text{We name the function }f;\text{ height is a function of age}.\\h=f(a)&&&&\text{We use parentheses to indicate the function input}\text{. }\\f(a)&&&&\text{We name the function }f;\text{ the expression is read as “}f\text{ of }a\text{.”}\end{array} $$

Remember, we can use any letter to name the function; the notation \(h(a)\) shows us that \(h\) depends on \(a\). The value a  a must be put into the function \(h\) to get a result. The parentheses indicate that age is input into the function; they do not indicate multiplication.

We can also give an algebraic expression as the input to a function. For example \(f(a+b)\) means "first add a and b, and the result is the input for the function f." The operations must be performed in this order to obtain the correct result.

Function Notation

The notation \(y=f(x)\) defines a function named \(f\). This is read as "\(y is a function of x\)". The letter \(x\) represents the input value, or independent variable. The letter \(y\), or \(f(x)\), represents the output value, or dependent variable.

Abenaki is an Algonquian language, related to other languages like Lenape and Ojibwe. We have included twenty basic Algonquin words here.

Algonquin Word Set