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359 Cards in this Set

  • Front
  • Back
when do you need an order for restraints
within one hour unless serious risk to you or patient.
are there prn orders for restraints
no
how often do restraint orders need to be renewed
every 24 hours on non leathers
can you use a physical and chemical restraint at the same time
no only one at a time
can you put a patient in spread eagle
no
how many side rails are considered a restraint
if all 4 are up
what are geri chairs
restraints
what should you document when giving a restraint
that you tried other approaches, date and time the restraint is applied, type of restraint, and notification of patients family and physician. Include frequency of assessment, your findings, regular intervals, when the restraint is removed and nursing interventions
what other types of approaches can you use
diversion, low boy bed, electronic alarms, exercise, out to nurses station, get a sitter.
when should you check for when restraints are on
toileting-q3
circulation- q2 or more
two finger check for tightness
remove and do rom-q2
food and water
find flow sheets
use quick release knot
attach to frame not side rail
how many stages of skin break down of pressure are there
4 stages. later added 2 more stages (deep tissue injury and unstageable pressure ulcers)
how are the stages pregressed
starts as reddened, then raw, then tear/blister, then deteriorates to massive tunneling craters.
when should you intervene on a pressure ulcer
before you see red
what is suspected deep tissue injury
purple or maroon localiezed area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear.
what may a deep tissue injury be preceded by
tissue that is painful, firm, mushy, boggy, warmer or cooler and compared to adjacent tissue.
how might it be hard to detect a deep tissue injury in
dark individuals
how does a suspected deep tissue injury evolve
may include a thin lister over a dark wound bed, the wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment
how d you characterize stage one pressure ulcer
intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Dig pigmented skin may not have visible blanching. May be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May be difficult to detect in individuals with dark skin tones
how do you treat stage one pressure ulcer
use duoderm to protect skin integrity or tegaderm over duoderm if duoderm is rolling off
what is a stage 2 pressure ulcer
partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Partial thickness skin loss involving epidermis, dermis or both.
how is a stage 2 pressure ulcer presented
shiny or dry shallow ulcer without slough or bruising. This stake should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. Ulcer is superficial-presents as abrasion, blister or shallow center.
what is a ducubitus ulcer
stage 2 ulcer
how do you treat a stage 2 ulcer
use duoderm or curasol wound gel with dry dressing (if lightly draining)
what is used in colostomy wafers
pectin which is duoderm
what is a stage 3 pressure ulcer
full thickness tissue loss. subcutaneous fat may not be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
how deep do nose, ear occiput and malleolus tunneling go
they do not have subcutaneous tissue and can be shallow
what part of the body can develop extremely deep stage 3 pressure ulcers
areas of significant adiposity but bone and tendon is no visible or directly palpable.
how are stage 3 ulcers presented
as a deep crater. Full thickness kin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. Bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
what is a stage 4 pressure ulcer
full thickness tissue loss with exposed bone, tendon ro muscle. Often include undermining and tunneling.
where do stage 4 pressure ulcers extend to
into muscle and or supporting structures such as fasica, tendon or joint capsule making osteomyelitis possible
how do you document tunneling
stick qtip in a say how far it goes in a the time
what is an unstageable pressure ulcer
full thickness tissue loss in which the base of the ulcer is cover by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown or black) in the wound bed.
why is is called unstageable
cannot stage what you cannot see
what might be unstageable
surgical debridement, necrosis???
what is maceration
ongoing contact with excessive moisture softens the skin, turns it white and causes it to breakdown. Exudate leaked from ulcers can also cause maceration, leading to larger ulcers or satellite ulcers
how are heel ulcers treat differently than sacral area
won't be surgically treated
what do you do for skin tear and tape burns
don't use tegaderm, used gentle clean, roll skin back, use petroleum gauze
what is a pressure ulcer
called decubius or decubiti and is caused by the pressure of the patients own body weight preventing blood flow to tissues causing
what is decubiti
a bedsore
what is the amount of direct pressure on the skin to have skin necrosis
greater than 32 mm Hg for capillary perfusion pressure for as little as 2 hours
after short periods of immobilization how high do sacral pressure reach
70 mm Hg
what is the pressure under the unsupported heel averages
45 mm Hg
how often do you want to move someone
atleast every 2 hours
what does pressure depend on
position in bed
what is important is skin integrity
nutritional status, hydration, proteins should be given.
what should you do if a person is stuck in lateral position
small position changes are helpful, skin prep, assess, first see red spongy then break down, nutrition- proteins-more later, hydration, keep pt dry as a skin barrier, draw sheets.
what is a normal prealbumin level
15-30 and half life is 2 days.
what is normal albumin levels
3.5-5.0. half life is 20 days.
what is the difference between prealbumin and albumin
prealbumin will show you changes in nutritional status over the last 7 days
how do you treat pressure ulcers
key is prevention. Assess pressure points and nutrition. Use dressing to keep ulcer moist but remember not to get surrounding tissue wet. Don't use betadine or hydrogen peroxide, use a vac.
how should you pack an ulcer
loosely
how should you ask you patient before treating ulcer
if they want pain medicine
what is the braden scale
six pint assessment tool for skin breakdown. Pressure sore risk
what are the 6 points of the braden scale
sensory perception, moisture, activity, mobility, nutrition, friction and sheer
how is sensory perception scored on the braden scale
ability to respond meaningfully to pressure related discomfort.
1: completely limited: unresponsive to painful stimuli
2. very limited: resonds only to painful stimuli
3. slightly limited: responds to verbal commands but cannot always communicate discomfort
4. no impairment: responds to verbal commands and has no sensory deficit
how is moisture scored on the braden scale
degree skin is exposed to moisture
1. constantly moist-skin is moist almost constantly by perspiration, urine, ect.
2. moist-skin is often but not always moist, linen changed atleast once a shift
3. occasionally moist- skin is occasionally, linen change x1
4. rarely moist-skin is usually dry, linen requires changing only at routine intervals
how is activity scored on the braden scale
degree of physical activity
1. bedfast-confined to bed
2. chairfast- ability to walk severely limited or nonexistent. Cannot bear own weight
3. walks occasionally- walks occasionally during day but for very short distances, spends majority of each shift in bed or chair
4. walks frequently- walks outside the room at least twice a day and inside room at least once every two hours during waking hours
how is mobility scored on the braden scale
ability to change and control body position
1. Completely immobile-does not even make slight changes in body or extremity position without assistance
2. Very limited- makes occasional slight change in body or extremity position but unable to make frequent or significant changes independently
3. slightly limited-makes frequent though slight changes in body or extremity position independently
4. no limitations
what can raising bed do to the skin
cause shearing
what is shear
the result of skin being pulled in one direction, however supporting structures such as muscle and bone do not move, or move in the opposite direction.
what is friction
the result of the skin being moved one way while a surface is stationary or moves in the opposite direction
how is friction and shear scored on the braden scale
1. Problem- requires moderate to maximum assistance. Frequently slides down in bed or chair. Spasticity, contractures leads to almost constant friction.
2. Potential problem- moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position
3. No apparent problem: moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.
how do you move patient to head of bed
use two people at minimum. use draw sheet. put HOB down. tell patient to cross arms and have knees bent, heels on bed and chin down.
when should you document skin assessment
on admission
what should you document about skin assessment
prevention as well as treatment and education. Document stage, length, width, depth, tunneling.
what are the nursing diagnosis of skin
impaired tissue integrity, ineffective tissue perfusion, pain. at risk for infection, care giver strain
what are the hazards of bed rest beyond pressure ulcers
loss of muscle mass and bone density, hight potential for neuro involvement, DVT. Also have impact on cardiac, pulmonary and mental systems.
what does bed rest do to nutrition
leads to reduced stimulation of whole-body protein synthesis by amino acid administration.
what does recumbent position do to hydrostatic pressure
loss of most hydrostatic pressure below heart, and reduced muscular force of all bones, and reduced total energy utilization
how is the cardiopulmonary system effected by bed rest
results in loss of plasma volume and CO is effected.
how is the pulmonary system effected by bed rest
supine reduces ventilation even more by increasing the closing volume enough to cause an additional fall in PaO2 2-8 mm Hg
how is neuro system affected by bed rest
sensory deprivation or overstimulation results in confusion and delirium. Developing subjective sensory distortions
how do you prevent hazards of bedrest
positioning, ROM, exercise in bed.
what do you do to assess the joints
inspect, palpate, ROM, strength
Why do you do ROM
to see if motion is limited by a mechanical problem within the joint, swelling of tissue around joint, spasticity of the muscles, pain or disease.
what is a contracture
fixed tightening of muscle tendons, ligaments, or skin. prevents normal movement of the associated body part.
what is the best kind of ROM
active
if you have to do passive ROM what do you do
extend, flex and rotate. imitate normal movements
How often should you do passive ROM
once per day. Each 10 times to the point of resistance.
how do you do passive ROM
do it slowly, watching pts face for pain, move until pt feels a slight stretch, but don't force a movement. Move only to the point of resistance, keep limbs support throughout motion.
how do you do hip and knee flexion
push knee toward chest.
how do you do hip rotation
bend the knee halfway to the chest with 90 degree angle between knee and hip, push foot away from you then pull foot toward you.
how do you assess hip abduction
pull straight leg toward you
how do you ankle rotation
turn foot inward and outward
how do you do toe flexion
pull toes forward and push forward
how do you do heel cord stretching
place forearm against the ball of the foot. Push the ball of the foot forward, bending the foot toward the knee and stretching the muscles in the back of the leg
when should you do ROM
before getting patient out of bed.
what muscles and how do you assess
shoulder flexion, wrist extension, elbow extension and flexion, grip, hip flexion, knee flexion and extension, ankle plantar flexion and dorsiflexion
which action is believed to be most useful in preventing wound infections
performing careful hand hygiene
what is the type of moist heat application
a sitz bath. Aquathermia pad, hot water bag, and commercial hot packs are dry heat.
what action would be a priority in preventing a patient form developing a pressure ulcer.
using a mild cleansing agent when cleansing the skin
what do you do to prevent pressure ulcers in patients in supine
use padding, use air bed, turning, skin prep, skin barriers on, bonny boots/heel elbow protectors on.
what are the phases of wound healing
hemostasis, inflammatory phase, proliferation phase maturation phase.
what are factors that affect wound healing
local factors and systemic factors
what are local factors that affect wound healing
pressure, desiccation, maceration, trauma, edema, infection, necrosis
what is desiccation
dehydration
what is maceration
over hydration
what are systemic factors that affect wound healing
age, circulation and oxygenation, nutritional status, wound condition, medications and health status
what is dehiscence
partial or total separation of wound layers as a result of excessive stress on wound that are not healed but muscle is still intact.
what is evisceration
wound completely separates with protrusion of viscera through the incisional area. Protruding bowl ect. can occur.
what is a fistula
abnormal passage from an internal organ to the outside of the body or from one internal organ to another.
what are the factors in pressure ulcer development
external pressure the compresses blood vessels and friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
what is local anemia resulting from poor circulation called
ischemia
what should the nurse assess for wounds
skin assessment, nursing history, pain assessment, wound assessment, pressure ulcer assessment
what do you assess in wound assessment
appearance, drainage, sutures and staples
what do you assess in pressure ulcer assessment
risk assessment, appearance, mobility, nutritional status, moisture and incontinence.
what is a normal potassium level
3.5-5.0
what should you say when labs are out of safe range
symptoms, vital signs, what meds, what IV is running, I and O per hour check EKG, allergies, LOC, pain. Have chart in front of you.
what are factors influencing communication
developmental level especially for transfer of information, Gender for you and patient, sociocultural gender differences, language and the culture of the hospital. Prior relationships, and hierarchy
what is the root cause of sentinel events
communication problems
why are they called sentinel events
because they signal the need for immediate investigation and response.
why does communication break down
different communication styles, high level of activity, frequent interruptions, no standardization in organizing essential information
what is the result of communication break down
loss of information
what are nurses communication styles
narrative and descriptive
what are physician communication styles
guided to be problem solvers "just the facts please"
what is SBAR
a framework for communication to keep patient safe. Situation, Background, Assessment, Recommendation
what is situation
the problem
what is background
brief, related, to the point
what is assessment
what you found, what you think
what is recommendation
what you want
what do you state in situation
Name and unit, who you are calling about, the problem.
what do you state in background
state the admission diagnosis and date of admission, state the pertinent medical history, a brief synopsis of the treatment to date
what do you state in assessment
pertinent objective and subjective information for you to decide. Can state vitals, mental status, respiratory rate and quality, blood pressure, pulse rate and quality, pain, neuro changes, skin color, rhythm changes in input and output
what do you state in recommendation
what you would like to see done. Can be to transfer the patient, change treatment, come to see the patient at this time, talk to the family and patient about something, ask for a consulting physician to see the patient
what should you ask for in recommendation
if the patient does not improve, when would you want to be called again
when talking to a family you should never
say anything with out a purpose
what is intrapersonal level of communication
talking to yourself... such as a pep talk. Often where spiritual aspects arise
how can patients and nurses communicate
eye contact, facial expression, posture and gait, touch, gestures, sounds, cry, hummph. Never say oops as a nurse.
what is communication via touch
can be used as a distracter from pain. Pain is worse when alone. Hand is often most effective to show you care, they can tell your there especially if there eyes are clossed.
what does communicating via actions do
actions speak louder than words. Explain your actions when they can be misconstrued. Say 'For you' a lot
what does communicating with space do
use space especially if patient is angry. Often evaporates in emergency.
when should you use open questioning
when a patient says something like i don't feel so well
when should you use closed questioning
when a patient says something like i am having chest pain
what is the difference between a helping relationship vs. a friendship
helping occurs for a specific purpose with a specific person. it is purposeful and time limited. You never know where next answer will take you such as asking about a son in pre open heart if son is dead
what are some barriers to communication
hearing, mental, physical, emotional state, foreign language, special needs such as coma, vents, aphasia, infant ect.
what are reasons for patient teaching
Illness/injury prevention such as for immunizations, health screenings, safety
what are other reasons for patient teaching
health restoration such as medication information, treatment implementation, the illness anatomy and physiology, signs and symptoms, significance and what to
do.
Facilitating coping-stress management, grief counseling, referrals for PT, self help groups, etc
what should you teach all patients about falling
it could open incision, if person is on anticoagulant
what are the ABCS of falling
Age, bone, coagulants, surgery-mean high risk for serious injury
how do you teach diabetics
start where they want, teach about measuring glucose, injections, and diet, exercise, and stress
what should teach your patient in pre up
will they wake in ICU of ventilator, pain control, tubes they will have, when they come out, when they are allowed to get out of bed, if they have a blood glucose monitor, teach them to practice deep breathing to prepare
what is noncompliance associated with
patient confusion, disappointment, misunderstanding, fear, or inadequate finances
what are the systems associated with urinary elimination
cardiovascular, renal, neuro.
what is the renal function
filter blood/waste products, excrete urine, maintain fluid, electrolyte, acid base balance
what is the process you should to for functional status of GI and GU
ADPIE
what is the fluid balance affected by or have an impact on
GI, GU, cardiact, pulmonary, renal, skin integrity, meantal satus.
How closely you look at I and O depends on what
Patient condition such as ESRD, liver failure, fresh MI, CHF, fresh post op and tools.
I and O gives you a rough assessment of balance and kidney G/U function only if
there is no other drainage, no internal fluid shifts, no obstruction or no inability to void.
what are some reasons to catheterize a patient
monitoring of critically ill patients for accurate I and O, urinary retention especially post op and epidural for pain, obtaining a sterile urine specimen, surgery. Dont use for incontinent patient unless in extreme case it is delaying healing of a wound
on a foley cath what tells you how much water to put in and take out
the balloon port
what is a coude catheter
designed with a curved tip that makes it easier to thread the catheter past the prostate or obstructions in the urethral canal. Hockey stick up to umbilicus
what is a urinary diversion ileal conduit
diversion of rueters to the ileum, ileum brough to abdominal wall. Stoma opening is urostomy
what are the GU assessment labs
BUN, Cr, Na, GFR or eGFR
what is a normal BUN level
5-20
what is a normal Cr level
.5-1.5
what is a normal Na level
135-145
what does BUN levels indicate
renal and liver function
what does an increase in BUN mean
Renal disease, GI bleed, shock, dehydration, CHF, MI
what does a low BUN signify
liver failure, malnutrition, over hydration
what is creatinine
breakdown of creatine, an important component of muscle
what can creatinine be converted to
the ATP molecule, which is a high energy source
what is the significance of creatinine
creatinine is excreted form the body entirely by the kidneys and with normal renal excretory function, serum creatinine level remains normal
what can cause changes in creatinine
acute tubular necrosis, dehydration, preeclampsia, hypertension, glomerulonephritis, pyelonephritis, reduced renal blood flow from shock and congestive heart failure, renal failure, rhabdomyolysis, diabetic nephropathy, urinary tract obstruction
how is sodium related to the GU system
it is the main extracellular cation. Related to blood pressure by its working of nerves and muscles
what are the causes of hyponatremia
cirrhosis, vomiting, kidney disease, diarrhea, SIADH (syndrome of inappropriate antidiuretic hormone)
what are the causes of hypernatremia
diabetes insipidus, hyperaldosteronism, cushings syndrome or salt or sodium bicarbonate ingestion.
what is the GFR of stages of kidney failure
130-90, 90-60, 60-30, 30-15, 15-0 (renal failure)
when do you need a kidney transplant
stages 1 through 5
when do you need dialysis
stage 5
what questions should you ask for urinary elimination assessment
any problems, frequency, urgency, burning, retention, color, clear cloudy sediment clots, amount if measured.
what makes urine output low
obstruction or retention, light on fluids
what is the bladder is not palpable
it is empty
what if the bladder is moderately full
palpation above pubis
what if the bladder is full
palpation may be close to umbilicus
what is anuria
no or less than 100cc in 24 hours
what is oliguria
decrease production of urine. 100-400 cc's in 24 hours
what is nocturia
increased frequency in the night
what is hematuria
blood in urine
what is the minimum assessment of the abdomen
inspection and palpation
what do you check for with inspection and palpation of abdomen
if it is round, flat, distended, symmetric, tender, soft
what is an inguinal hernia
occurs when part of an organ (usually the intestines) sticks
through a weak point or tear in the thin muscular wall that holds the
abdominal organs in place. Seen near bladder
what is lymphogranuloma venereum
enlarged inguinal and femoral lymph nodes separated by a groove made by the inguinal ligament
what is a caput medusae
the appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins.
what can happen in portal hypertension
dilated veins are draining towards the superior vena cava, gynaecomastia and dilated surface veins, and dilated veins drain away from the umbilicus to the caval circulation
what is ascites
central protuberance with a stretched umbilicus. Abdomen symetrically distended secondary to fluid buildup in peritoneal cavity. Note bulging flanks as fluid distributes to most dependent areas of abdomen. Skin also yellow due to hyperbuilirubinemia
have causes ascites
alcohol
what are the cage questions
questions to assess alcoholism
what is C is cage questions
have you ever felt that you should cut down on your drinking
what is the A cage question
have people annoyed you by criticizing your drinking
what is the G cage question
have you ever felt bad or guilty or drinking
what is the E cage question
have you ever had a drink first thing in the morning to stead your nerves or get rid of a hangover
what is an incarcerated umbilical hernia
note reddened umbilical area resulting from entrapment of intra abdominal contents in hernia. When is occurred the patient developed acute pain in this region
what is rectus diastasis
separation of rectus abdominus muscles, occurs in older patients and or those with weakening of the abdominal musculature. The hernia can be made more apparent by increasing intra abdominal pressure. Have head up.
what do you ask in your GI assessment
when was your last BM, formed, color, soft? Do you take anything to have a BM? What is your norm at home, any nausea or vomiting, and you passing any flatus
who should be especially considered when asking about flatus
post op patients
what should you use to assess for vascular bruits
bell
what can cause diarrhea
infectious agents, malabsorption, inflammatory processes, structural changes, side effects of medication, laxative/enema abuse
what can cause constipation
diet, dehydration, diverticular disease, neuropathy, immobility, medication, gynecological problems
what causes fecal incontinence
anal sphincter dysfunction, compromised rectal function, anatomical defects
what are some nursing diagsosis associated with GI
bowel incontinence, constipation, diarrhea, fluid volume deficit, electrolyte imbalance, disturbed self esteem image, caregiver role stain, toileting self care deficit, impaired skin integrity
what is the nursing process on bowel elimination
platn: restore patients regular elimination patterns, prevent complications through patient education.
Implementation: Increased fluid intake, high fiber diet, decrease smoking and alcohol, decrease stress, environmental modification, bowel regiment/stimulation, rectal bad/tube
what does caffeine do to the bladder
it irritates the bladder mucosa
what happens to urine if the patient has a fever or diaphoresis
the urine output will be decreased and highly concentrated
what are kegal exercises
exercises that target the inner muscles that lie under and support the bladder and can help a patient regain control of the micturition precess
what is enuresis
bed wetting
what is maturational enuresis
child bed wetting at night
what is an enema
he procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and complete evacuation of the lower intestinal tract.
does alcohol a laxative or constipation effect
laxative
what is a fecal impaction
a solid, immobile bulk of stool that can develop in the rectum as a result of chronic constipation.
what is an ileostomy
s a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out of the ileostomy and is collected in an external pouching system stuck to the skin.
what do emollients do
lubricate the stool
what do lubricant laxatives do
soften the stool making it easier to pass
what do stimulant laxatives do
promote peristalsis by irritating the intestinal mucosa or simulating nerve endings in the intestinal wall
what do bulk forming laxatives do
causes the stool to absorb water and swell
what does barium enema do
radiographic examination of the large intestine
what does habitual use of laxatives do
cause chronic constipation
what can happen in removing a fecal impaction manually
stimulation of the vagal nerve and resulting bradycardia
what position facilitates the passage of flatus
knee chest
what is congenital analgesia
lack of ability to experience pain and causes multiple health problems
what is pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
is pain proportional to issue damage
no
is pain objective or subjective
subjective
what does pain do
inhibits the immune system and can enhance tumor growth, gastric and bowel motility goes down, have bed rest hazards, adds decrease in fluids, constipation. endocrine problems, respiratory problems, cardiovascular problems, sleeplessness, anxiety, hopelessness, thoughts of suicide
WHAT ARE RESPIRATORY CONSEQUENCE OF UNRELIEVED PAIN
flow and volume go down, atelectasis, shunting goes up, cough goes down, sputum retention goes up.
what do you give for pain
opioids
why are opioids feared
they can be addictive and respiratory depression
what are the 3 types of pain
acute, cancer, chronic nonmalignant
what is nociceptive pain
stimulus from somatic and visceral structures
what is neuropathic pain
stimulus abnormally processed by the nervous system
what are nociceptors
free nerve ending responding to noxious or innocuous stimuli. specialized nerve ending responding to normal pain (thermal, chemical, mechanical)
what is nociception
term used to describe how pain becomes conscious
what are the four processes that must work for pain to become conscious
transduction, transmission, perception, modulation
what is transduction
nocieptors receive sufficient stimuli from tumor, incision, crushing injury, or burn, tissue damage occus and the trauma causes release of histamine, bradykinin, serotonin, and protaglandins
what interferes with prostaglandins
NSAIDs and corticosteriods
what is transmission
the pain stimuli has to become an impulse to move from periphery to the cord, noxious stimuli cause the membrane to become permeable and action potential occurs
what do you use to block Na and K from moving in and out of the cell
anticonvulsants block Na channels and local anesthetics block Na completely
how can you modify pain perception
use imagery, relaxation, distraction
what is modulation
now on the descending pain system, neurons release neurotensin, GABA, serotonin, endogenous opioid
what do antidepressants do for pain
interfere with the bodys uptake of serotonin that increases its availability to inhibit noxious stimuli
what is adjuvant
a drug that has a primary indication other than pain but is a useful analgestic such as muscle relaxant (steroids)
what do you use Ca and beta blockers and lithium for
migraines and cluster headaches
what do you use clonidine for
hypertension and pain
what is a mu agonist
a type of opioid like morphine that relieves pain by binding to the Mu receptor sites in the nervous system
what are opioids
codeine, morphine, fentynl and other drugs relieving pain by binding to multiple types of opioid receptors in the nervous system. have cns and periphery effects
what do genetic differences (polymorphisms) result in pain
a wide range of analgestic responses
when should you start thinking it is time to treat pain
when patient says pain is a 4
what is on the pain assessment score
facial expression, cry, breathing patterns, arms, legs, state of arousal
how is the pain assessment scored
all categories are 0 or 1 except crying is 0-2
what is the hierarchy of pain assessment
patient self report then patient behavior, the reports of family, then physiologic.
what should you check in patients taking opioids
count the respirations
what is the LOC scale
1. sleeping
2. alert or easy to arouse
3. occasionally drowsy easy to arouse
4. frequently drowsy
5. somnolent-difficult to arouse
what do you use clonidine for
hypertension and pain
what is a mu agonist
a type of opioid like morphine that relieves pain by binding to the Mu receptor sites in the nervous system
what are opioids
codeine, morphine, fentynl and other drugs relieving pain by binding to multiple types of opioid receptors in the nervous system. have cns and periphery effects
what do genetic differences (polymorphisms) result in pain
a wide range of analgestic responses
when should you start thinking it is time to treat pain
when patient says pain is a 4
what is on the pain assessment score
facial expression, cry, breathing patterns, arms, legs, state of arousal
how is the pain assessment scored
all categories are 0 or 1 except crying is 0-2
what is the hierarchy of pain assessment
patient self report then patient behavior, the reports of family, then physiologic.
what should you check in patients taking opioids
count the respirations
what is the LOC scale
1. sleeping
2. alert or easy to arouse
3. occasionally drowsy easy to arouse
4. frequently drowsy
5. somnolent-difficult to arouse
what are the meds levels
first rung-non opiods (tylenol), NSAIDS (ibuprofen, adjuvants)
2nd rung- opioids in combination
3rd rung-morphine dilaudid fentanyl. opioids not in combination
what do you assess in pain
intensity, quality, onset, duration, relived by, increased by,
what is the neuropathy scale
measure pain, if it is intense pain, sharp, hot, dull, cold, sensitive, itcy
what is an intrathecal drug pump
pump/reservoir implanted between the muscle and skin of abdomen. catheter carries pain medication from the pump to the spinal cord and nerves
what should you do if you put a limb down
hold it for a brief moment
what is sleep regulated by
sleep/wake restorative process and circadian biological clock
what the the mechanism that underlies endogenous circadian rhythms
earths rotation on its axis
what are the similarities of REM and NREM sleep
posture, unresponsiveness, reversibility, lack of conscious awareness
what are the differences between REM and NREM sleep
brain blood flow, glucose utilization, neurotransmitters, thalamic function
what happens to heart rate, respiratory rate, blood pressure, alveolar ventilation and skeletal muscle tone in stages 1-4 of sleeping
goes down
what is the respiratory rate in rem sleep
irregular
what is the skeletal muscle tone in rem sleep
atonia
what are factors affecting sleep
age, motivation, sleep hygiene, activity, caffeine, beverages, food, alcohol, smoking, sleep environment, illness, and medications
what is the cause of sleep apnea in children
enlarged tonsil and adenoids, childhood obesity associated with poor school performance and impaired growth
what are some sleep problems in children and young adults
enuresis, somnambulism, bruxism, delayed sleep phase.
what are the effects of caffeine on sleep
competes for adenosine receptors (inhibitory neurotransmitter that induces sleep)
what are the effects of alcohol on sleep
sympathetic arousal with decline in blood level
what is somnambulism
sleep walking
what is bruxism
grinding of teeth
what are the problems in sleeping in adults
narcolepsy, restless legs syndrome, obstructive and central sleep apnea
what is the sleep assessment
bedtime, excessive daytime sleepiness, awakenings: night waking and early morning waking, regularity and duration of sleep, snoring
what are the sleep quality self assessment instruments
Pittsburgh sleep quality index, epworth sleepiness scale
what is the epworth sleepiness scale
gives 8 situations and has a 0-3 chance of dozing
what are the physiological measures of sleep
polysomnography, multiple sleep latency test.
when should you give a polysomnography
during the day, usually at 2- hour intervals to estimate time to fall asleep. assesses severity of daytime sleepiness what are common circadian disruptions
what is effected by sleep deprivation
cognitive abilities and mood such as memory, paying attention to and completing tasks, hard to concentrate, solve problems and make decisions.
what are health consequences of inadequate sleep
OSAH in patients with diabetes in hypertensive men. obesity
what are possible nursing diagnosis
disturbed sleep pattern, sleep deprivation
how do you get better sleep hygiene
make bedroom good to sleep in, exercise during the day, have adequate time in bed, relax, avoid caffeine, alcohol, eat healthy, sleep during the dark of night.
when should you refer to sleep center
longer than 30 minutes to fall asleep on 3 or more nights/week. Multiple awakenings during the night more than 2 nights/week. Falling asleep during the day without deliberate effort, patient or partner reports of excessive limb movements, loud snoring or cessation of breathing
how can lifestyle affect sexuality
stress can affect sexual expression
what are factors affecting sexuality
developmental considerations, culture, religion, ethics, lifestyle, childbearing, STD or STI, heath state
what are health states affecting sexuality
chronic pain, diabetes mellitus, cardiovascular disease, diseases of the joint and mobility, surgery and body image, spinal cord injuries, mental illness, medications
what are some male sexual dysfunctions
erectile failure, premature ejaculation, retarded ejaculation
what causes retarded ejaculation
interpersonal problems
what are some female sexual dysfunctions
inhibited sexual desire (orgasmic dysfunction), dysparenia, vaginismus, vuvlodynia
what causes inhibited sexual desire
anxiety, negative emotions, fear, physical factors
what is dysparenia
painful intercourse
what is vaginismus
vaginal opening is closed tightly and prevents penitration. Secondary to involuntary spastic muscle contractions at and around the vaginal opening and the levator ani muscles
what is vuvlodynia
a chronic vulvar discomfort characterized by burning, stinging, irritation, or rawness of the female genitalia that interferes with sexual intercourse
what are categories of patients requiring sexual history
patients seeking care for pregnancy, STDs, infertility, contraception, patients experiencing sexual dysfunction, patients whose illness will affect sexual function
what is level 1 of watts general levels of sexual history
part of comprehensive health history, obtained by a nurse
what is level 2 of watts general levels of sexual history
sexual history
what is level 3 of watts general levels of sexual history
sexual problem history
what is level 4 of watts general levels of sexual history
psychiatric/psychosocial history, obtained by a psychiatric nurse clinician
how do you obtain sexual information
description of the problem, onset and cause of the problem, past attempts at resolution, goals of the patient
what are patient outcomes regarding sexuality
define individual sexuality, establish open patterns of communication with significant others, develop self-awareness and body awareness, describe responsible sexual health self care practices, practice responsible expression
what are basic charting methods to predict ovulation
temperature method, cervical mucus method, calendar method
what is aspiration
something other than air is inhaled into the lungs or trachea
what are causes of aspiration
cranial nerves 5, 7, 9, 10 and 12, 9 and 10 for speech, physical abnormalities, tubes ect.
what do you assess for aspiration
loc, gag, speech, lungs
how do you help with aspiration
put hob up to 60 for 2 hours, get swallowing evaluation
what is the semisolid swallowing trial
thicken water with a thickener to make it pudding like and assess for deglutition, coughing, drooling, and voice change
what is the liquid swallowing trial
check liquid swallowing starting with 3mL and then increase if possible
what is the solid swallowing trial
small bread is used
what is the first tier of swallowing
patient does not have a cervical or tracheostomy, no previous history of swallowing disorder, patient is able to understand what you are saying, can sit at a 90 degree angle or not less than 60 degrees, patients chin is able to be parallel to the floor, can remain alert, body is or can be midline to the bed
what d you do if all items of first tier are not checked
reassess bid, obtain speech therapy consult
what is the second tier
patient is not experiencing respiratory distress, patient is not experiencing poor secretion managemetn requiring NT or oral suction, normal voice quality without wetness, gurgling, weakness or whispering, able to produce effective cough
what is superficial spreading melanoma
generally the most common form of melanoma
what is horners syndrome
loss of sympathetic nervous system input to eyes. Pupil is smaller and eyelid covers a great portion of the eye.
what is lcterus
yellow discoloration of the sclera caused by hyperbilirubinema
what is conjunctivis
marked bilateral inflammation involving conjunctive that covers sclera and under surface of eyelid
what are manifestations of ocular graves' disease
hyperthyroidism, weight loss, increased appetite, nervousness, palpitations, tacycardia, hypertension, hyperrelexia,
what does macular degeneration do
induces image distortion and dark areas
what is retinitis pigmentosa
small flashes of light or a twinkling, shimmering sensation in the midperipheral or peripheral field from aberrant electrical impulses from the degeneration retina. presence of dark pigmented spots in the retina
what is a parotid gland
enlarged right parotid gland secondary to lymphoma
what is angioedema
acute selling of the lips from an allergic response to medication
what is cellulitis
redness and swelling form bacterial skin infection
what should you look for in the vomit
color, amount, onset duration, frequency, severity, projectile, precipitating factor
what should you assess in nausea and vomiting patient
bowel perforation, soft, distended bowl sounds, dehydration, lyte imbalance, changes in CO, renal function, bleeding, K, Na, H and H.
what are the causes of early morning vomiting
pregnancy, uremia, alcohol, increased intercranial pressure
what are the causes of vomiting
dehydration, aberrant motion, pregnancy, medications such as opioids and chemotherapy drugs
what should you assess in nausea
onset, duration, frequency, color, amount, accompanying diarrhea, associations, such as environment, and anesthesia and narcotics, auscultate bowel sounds, passing flatus, monitor I and O, monitor vital signs, electrolytes, hematocrit,
what should you do for patient who is nausea
give an emesis basin, give call light, lower lights, give cool cloth, rid room of strong odors or food smells, give zofran, reglan, or compazine, give ice chips not water, give IV for hydration, give flat ginger ale, coke, crackers, no diet soda
what should you do if patient vomits
water to rinse, brush teeth, moist cloth for cleaning, remove emesis immediately
when should you use on NG
if bowel is not functioning is the cause of vomiting
what is noise
acoustic signals which can negatively affect the physiological or psychological well being of an individual
how many decibles can cause harm
100 should not be more than 15 minutes, 110 for 1 minute can risk permanent hearing loss
what causes hearing loss
hair cells in cochlea are damaged and cant transmit sounds. it is damage to the delicate mechanosensory apparatus of the hair cell stereocilia
what do loud sounds cause
cardiovascular effects such as hypertension and arrthymias, incrases breathing rate, distrubs digestion, can cause an upset stomach or ulcer, negatively disrupts fetus, premature birth, makes it difficult to sleep, fatigue, and reduced work output
what is tinnitus
the perception of sound within the human ear in the absence of corresponding external sound.'ringing'
what should your priorities be in a fire in the hospital
RACE-
Rescue patients in area
Alert other personnel
Contain the fire
Extinguish and or evacuate
what is a class A fire
ordinary combustibles or fibrous material such as wood, paper, cloth, rubber and some plastics.
what is a class B fire
flammable or combustible liquids such as gasoline, kerosene, paint, paint thinners and propane
what is a class C fire
energized electrical equipment such as appliances, switches, panel boxes and power tools
what is a class D fire
certain combustible metals, such as magnesium, titanium, potassium and sodium.
what does a ground fault circuit interrupter do
detects an insulation failure by comparing the amount of current flowing to electrical equipment with the amount of current returning from the equipment
what are early on symptoms of being struck by lightning
intense headaches, ringing in the ears, dizziness, nausea, vomiting and other post concussion types of symptoms. May also experience difficult sleeping, develop seizure like activity several weeks to months after the injury, personality changes due to frontal lobe damage, they are irritable and easy to anger.
what are the four components of the precautionary principle
1. taking preventive action in the face of uncertainty
2. shifting the burden of proof to the proponents of an activity
3. exploring a wide range of alternatives to possibly harmful actions
4. increasing public participation in decision making
what are the effects of DDT
endocrine disrupting properties, disruption in semen quality, menstruation, gestational length, duration of lactation.
what is the half life of DDT
11 years
what can a pesticide cause
solid tumors, brain, prostate, kidney, and pancreatic cancer, leukemia, non hodgkin lymphoma, birth defects, fetal death, infertility, neurological problems
what happens in prenatal phthalate exposure
decrease in anogenital distance in male infants
what are advance directives
the legal documents such as the living will, durable power of attorney and health care proxy.
what does reave mean
forcible taken away
what do we see in nursing for grieving
the initial part, usually pain is blocked because of disbelief or too much to process.
what is a living will
document that allows individuals t record specific instructions about the type of healthcare they would like to reveive in particular endo of lif situations
what is the durable power of attorney
appointing someone to make decisions on healthcare