Nursing Interventions Module 1

Front 1

single most effective way to prevent spread of infection

Back 1

hand hygiene

Front 2

how to wash hands

Back 2

rub hands for 15-30 seconds to remove soil/ dead skin cells

rinse hands 15-30 seconds with water flowing towards finger tips,

dry from finger tips to wrist

turn off faucet with paper towel, not hands

Front 3

When should you wash hands

Back 3

before/ after meeting patient/ patient contact

when ever you put on or take off gloves

before passing medicine

after you sneeze

before you eat

Front 4

4 components of conducting a health assessment

Back 4

1. inspection- looking over patient (sight, hearing, smell)

2. palpation (touching) (light (1cm), moderate (2-3 cm), deep (4 cm or more))

3. percussion (to determine how dense material or organ is beneath what you are percussing) (louder over air, soft over solid, moderate over liquid)

-three types- direct, blunt, indirect (flicking a finger against another finger that is pressed firmly against skin)

4. auscultation (uses stethoscope)

- has bell (smaller end, low pitched sounds) and diaphragm (bigger end- picks up high pitched sound best)

Typical order, but different for abdominal assessment

Front 5

gastric sounds

Back 5

tympany (gastric bubble)- loud musical drum like sound, high pitched

hyperresonance (emphysema)-booming quality over lungs

resonance (normal lungs)- less than hyperressonance, but same sound over lung

dullness (liver)- dull, short lived sound

flatness (muscle)- dead sound, very short, very dull

Front 6

How to hold stethoscope

Back 6

hold between second and third fingers

Front 7

General survey

Back 7

vital signs, height and weight module, observations

Front 8

acute pain

Back 8

rapid onset, varies with intensity, protective in nature (warns you of injury or potential for it)

Front 9

chronic

Back 9

intermittent or persistent, long standing pain, interferes with ability to function

Front 10

acute on chronic

Back 10

chronic pain and then acute exaccerbated pain. acute pain is treated first

Front 11

remission and exacerbation

Back 11

remission- no symptoms

exacerbation- when symptoms come back and maybe get worse

Front 12

cutaneous or superficial pain

Back 12

skin, paper cut, tend to be pretty painful due to nerve endings right there

Front 13

somatic pain

Back 13

tendons, ligaments, nerves, vessels, bones

diffuse pain, scattered

Front 14

visceral pain

Back 14

originating from body organs, poorly localized,

Front 15

referred pain

Back 15

perceived in an area that is distant from where the injury is

myocardial infraction

Front 16

neuropathic pain

Back 16

injury to peripheral or central nerves

pain from neck from compression of vertebrae, pain may also be in areas innervated by vertebrae

Front 17

intractable pain

Back 17

can't get down to goal of pain aggreed upon with the patient

Front 18

psychogenic pain

Back 18

no physical cause of pain, but has psychological origin

Front 19

is response to pain sympathetic or parasympathetic

Back 19

sympathetic, unless for very sustained

Front 20

psychological responses

Back 20

withdrawn, anxious, fearful, angry, tired, depressed etc.

Front 21

COLD ERA mnemonic to assess pain

Back 21

Character of the complaint/ pain

Onset of the symptom

Location of the complaint

Duration of the problem

Exacerbated by what

Relieved by what

Associated symptoms problem

Front 22

OLD CARTs mnemonic to assess pain

Back 22

Onset

Location

Duration

Character

Aggravating factors/ associated symptoms

Relieving factors

Temporal factors

Severity

Front 23

other pain assessment tools

Back 23

Wong Baker FACES Pain Rating Scale

0-10 numeric

visual analogue scale

abbey pain scale

Front 24

Wong Baker FACES scale

Back 24

language barrier, can't read, old adults, young children.

point to smiley faces, has multiple languages, talks about how much pain is interfering with function (concentration)

Front 25

numeric scale

Back 25

10 being most 0 being fine

has a color scale on the chart

Front 26

visual analog scale

Back 26

mark where their pain is on a scale,

a little bit vague and harder to interpret because their isn't anything quantible from it

Front 27

abbey pain scale

Back 27

dementia patients who can't verbalize

are they vocalizing if they are having pain- give them a number based on what it is

is there a change in body languages/ facial expressions

behavior changes

physiological changes (sympathetic nervous system)

physical changes

Front 28

TENS

Back 28

transcutaneous electrical nerve stimulation

alternative to using an analgesic

Front 29

4 different NANDA diagnosis for pain

Back 29

acute postoperative, pain (name site) (leg pain), pain, chronic pain