exam 3

• Describes the body’s general response to stress.
• Even though it is a physiologic response to stress, the response can be triggered by either physical or psychological stressors. Often called the neuro-endocrine response.

• Autonomic Nervous system activates the fight or flight response.
• Hormone levels rise to:
• 1.Increase energy and O2 levels
• 2.Increase cardiac output and BP
• 3.Increase mental alertness

• Body now attempts to adapt to stressor.
• VS, hormone levels and energy production return to normal.
• Stress is either managed, the body adapts, begins to repair and returns to homeostasis; or the stress is too great on the body and the adaptive mechanisms fail.

• Occurs when adaptive mechanisms are exhausted.
• Energy to maintain adaptation is depleted.  The body can no longer defend itself against the physical or psychological stressor.
• Illness leading to death if stressor remains.

• Occurs when a person, object or situation of value changes or is no longer inaccessible
• May be positive Marriage or Birth
• May be negative Divorce, death, job loss

• Actual
• recognized by others as well as by the person sustaining the loss Examples include loss of a child, spouse, job
• Perceived loss
• felt by the person but is intangible to others Examples include loss of youth, financial independence
• Maturation loss (Necessary loss)
• Experienced as the result of natural developmental processes
• Oldest sibling feels a loss when the second child is born
• Situational loss
• experienced as a result of an unpredictable event
• includes traumatic injury, disease, death, or national disaster
• Anticipatory loss
• person displays loss and grief behaviors for a loss that has yet to happen
• example-families with patients with life-threatening illnesses can lessen the impact of the actual loss

• Denial
• The person cannot accept the fact of the loss. It is a form of psychological protection from a loss that the person cannot yet bear.
• Anger
• The person expresses resistance or intense anger at god, other people, or the situation.
• Bargaining
• The person cushions and postpones awareness of the loss by trying to prevent it from happening.
• Depression
• The person realizes the full impact of the loss.
• Period of grief before death
• Characterized by crying and not speaking much.
• Acceptance
• The person incorporates the loss into life.
• Patient feels tranquil
• Accepted death and prepared to die

• self-esteem is an individual's overall feeling of self-worth.
• ◦Depression- decreases self esteem.
• Stress- reduces ability to function.
• Maslow identified 2 subsets of self esteem
• ◦1. Self esteem needs- strength, achievement, mastery, competence, and confidence in the world.
• ◦2.  Respect needs- need for esteem from others.  (status, dominance, recognition, attention, importance & appreciation.)
• Use communication techniques to facilitate an environment and activities that will increase self-esteem.(PT assuming assuming responsibility of her own care).
• ◦Help pt develop self esteem to complete a certain task.
• Promote feelings of acceptance & worthiness.

• Require 2 separate clinical exams including Induction of painful stimuli
• Papillary responses to light Apnea testing.
• Do not perform brain death testing when the patient is Hypothermic, Hypotensive
• Under the influence of neuromuscular blocking or barbiturates.
• These characteristics must be present for at least 24 hours before declaring death
• Lack of receptivity and responsiveness
• Lack of movement or breathing
• Flat encephalogram
• Higher brain death
• Irreversible loss of all “higher” brain functions, and cognitive function
• Shows the critical functions are the individual’s personality, conscious life, uniqueness, and capacity for remembering, judging, reasoning, acting, enjoying and worrying.

• Inability or difficulty swallowing
• Pitting edema
• Decreased gastrointestinal and urinary tract activity
• Bowel and bladder incontinence
• Loss of motion, sensation, and reflexes
• Elevated temperature, but cold or clammy skin; cyanosis (Mottling)
• Lowered blood pressure
• Noisy or irregular respiration
• Cheyne-Stokes respiration may or not lose consciousness
• Weak, slow or irregular pulse
• Restlessness or agitation
• Mottling or cyanosis of extremities

• Serous: clear, watery plasma
• Purulent: thick, yellow, green, tan, or brown
• Serosanguineous: pale, pink, mixture of clear and red fluid
• Sanguineous: bright red, indicates active bleeding

• Palliative Care
• aggressively managing the symptoms but not cure. 
• Taking care of the whole person including body, mind, spirit, heart, and soul Sees dying as natural and personal Goal-to give patients with life-threatening illness the best quality of life by aggressive management of symptoms without having a curative effect on the underlying illness.
• Hospice- care provided for people with terminal illness. Usually terminal within 6 months.

• Hospice Care
• Priority is shifted to managing pain and other symptoms.
• Focus on patient comfort.
• Usually with life expectancy less than six months but not always.
• Shift to hospice care when dying appears to be closer.

• Tap water
• Hypotonic Lower osmotic pressure than the fluid in the interstitial fluids; net flow of water is out of bowels & into tissues Net flow occurs slowly & defecation is stimulated before significant fluid is absorbed into the body Significant fluid can occur if multiple enemas given.
• Rapid colonic emptying
• Adults 500 – 1000 ml
• Infant 150 – 250 ml
• Hypotonic (tap water)
• Isotonic (normal saline solution)
• Both types of large volume enemas may be dangerous with weakened intestinal walls.
• Normal saline
• solution Isotonic Osmotic pressure is equal both in the enema fluid & in the body’s interstitial fluids, so no net gain or loss of fluid.
• Soap solution
• Mucosal irritant, stimulation defecation. Hypertonic solution Uses a smaller volume of fluid Higher osmotic pressure than intestinal fluids Net flow of water into the colon, leading to distention & stimulating the defecation reflex.
• Available commercially (i.e. “Fleets”)Administered in smaller volumes Draws water into the colon Stimulates defecation reflex Contraindicated when sodium retention is a problem.

• Place patient on left side (Sims positions)Lubricate approx 2 -3 inches of rectal tube Ask patient to take some deep breaths Insert rectal tube 2 – 3 inches into rectum
• If resistance is met, unclamp the tube & allow a small amount of the enema solution to enter.
• Withdraw the tube & then continue to insert. DO NOT FORCE THE TUBE.
• When enema completed, assist pt onto bedpan, BSC, or toilet.
• Remind them not to flush until you have observed results.

• The solution container should be no higher than 12 - 18 inches above the patient’s anus The higher the solution container is, the faster the flow will be & the more force /pressure will be experienced by the patient If the patient c/o fullness or cramping, clamp to stop the flow for 30 seconds Administer enema slowly (over 5 – 10 minutes)
• Encourage the pt to hold the enema for 5 – 15 minutes. When the urge to defecate is strong, assist the patient onto bedpan, BSC, or toilet. Remind them not to flush until you have observed results.

Type of enema administered How patient tolerated procedure Results obtained

If pt is allergic to iodine, benzalkonium chloride or other cleaning agent can be used. Introduce well lubricated catheter 2-3 inches into urethral meatus using sterile technique. Observe for urine to flow through catheter. Advance 1 inch more Inflate balloon, using provided syringe filled with 10 ml sterile water. Collect specimen as ordered.

• Transient
• Appears suddenly lasts for less than 6m
• Transient incontinence is usually caused by treatable factors (use of diuretics, confusion R/T infection or illness)
• Stress
• Increase intra-abdominal pressure 
• Stress incontinence when intra-abdominal pressure exceeds the urinary sphincter’s ability to stay closed (cough, sneeze, position changes)
• Urge
• loss of urine soon after feeling urgent need to void
• Mixed
• Two or more types of incontinence
• Overflow
• Over distended bladder
• Overflow: spilling off the top. The signal to empty the bladder is underactive or absent and there is urinary retention. This can be D/T side effects of drugs, fecal impaction, cystocele or neurologic conditions. 
• Functional
• Inability to reach the toilet because of environmental barriers, physical limitations, loss of memory
• Functional: inability to reach the toilet for a variety of factors (environmental barriers (to far away, up stairs), physical limitations (arthritis), or loss of memory.
• Reflex
• Emptying of bladder without the sensation to void
• Spinal cord patients
• Total
• Continuous and unpredictable

• Exercise- 30-45 min. 3-4 X per week . Walking is considered the single best method to relieve stress.
• Rest & sleep- provides insulation against stress. Use relaxation tech. if possible. Nutrition- Obesity & malnutrition stress body. Maintain body wt. & eat healthy.
• Encourage strong support systems, friendships.

• Actual
• recognized by others as well as by the person sustaining the loss
• Examples include loss of a child, spouse, job Perceived loss
• felt by the person but is intangible to others
• Examples include loss of youth, financial independence
• Maturational loss (Necessary loss)Experienced as the result of natural developmental processes Oldest sibling feels a loss when the second child is born 
• situational loss
•  experienced as a result of an unpredictable event includes traumatic injury, disease, death, or national disaster
• Anticipatory loss
• person displays loss and grief behaviors for a loss that has yet to happen example-families with patients with life-threatening illnesses can lessen the impact of the actual loss

• Irreversible cessation of circulatory and respiratory functions
• Irreversible cessation of all functions of the entire brain, including brainstem
• Higher brain death
• Irreversible loss of all “higher” brain functions, and cognitive function
• Shows the critical functions are the individual’s personality, conscious life, uniqueness, and capacity for remembering, judging, reasoning, acting, enjoying and worrying

breathing, food, water, sex, sleep, homeostasis, excretion

Anxiety: A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response. Source is nonspecific or unknown with a feeling of apprehension or anticipating a danger.

• Children need to grieve
• Loss of parent by middle aged adult helps prepare for loss of spouse and accept eventual death
• Older people lose spouse and friends-reminisce about life, put purpose of life in perspective and prepare for their own death
• Terminally ill children and siblings ask questions about death in an attempt to understand it
• Death of a parent or other significant person can slow child’s development or cause regression
• Children do not understand death on the same level as adults

• Nurse needs to support patient by: Indicating presence
• Give them your full attention
• Show that you care
• Encourage presence of family
• Encourage reminiscing
• Fears of the patient: pain, separation, unknown, leaving loved ones, loss of dignity, loss of control, unfinished business, isolation-being alone
• Nurse should contact the dying patient’s clergy for patient support and comfort
• Patient needs to feel their lives had meaning Patient need to feel hope even though they are dying

diminished ( small or decreased) urine secretion in relation to fluid intake.

painful or difficult urination