Exam 3 Flashcards

Question

Factors influencing heat and cold intolerance:

Answer 1

Method and duration of application exposed skin: neck, inner aspect of wrist and forearm and perineal region are more sensitive, foot and palm of the hand are less sensitive Amount of body surface covered by application Temperature: body responds best to minor temperature adjustments, or larger areas of exposure Age: very young and old most sensitve perception of stimuli: reduced sensory perception, risk for injury is high

Answer 2

Effects: constricts peripheral blood vessels reduces swelling and pain reduces muscle spasms prolonged exposure results in vasodilation Devices to apply cold: ice bags cold packs hypothermia blankets cold compresses to apply moist cold

Answer 3

Effects: dilates peripheral blood vessels and improves blood flow to area increase tissue metabolism reduces blood viscosity and increases capillary permeability reduces muscle tension and stiffness helps relieve pain prolonged exposure results in vasoconstriction and can lead to burns Devices: hot water bags electic heating pads aqua-thermia pads hot packs warm, moist compress sitz bath warm soaks

Answer 4

Acute: less than 3 months rapid onset, varies in intensity and duration protective in nature Chronic: more than 3 months may be limited, intermittent, or persistent last beyond the normal healing period idiopathic pain: no known cause periods of remission or exacerbation are common

Answer 5

Transduction: activation of pain receptors Transmission: conduction along pathways (A-delta and C-delta fibers) Perception of Pain: awareness of the characteristics of pain - pain threshold: point at which a person feels pain - pain tolerance: amount of pain a person is willing to bear Modulation: inhibitation or modification of pain

Answer 6

describes the transmission of painful stimuli and recognizes a relationship between pain and emotions small- and large diameters nerve fibers conduct and inhibit pain stimuli toward the brain Gating mechanism determines the impulses that reach the brain

Answer 7

Cutaneous: In the skin or subcutaneous Ex: superficial cut, bee sting Somatic: deep and diffuse (sharp, stabbing pain, localized) ligaments, tendons, blood vessels, and bones Ex: arthritis, bone fracture, or cancer Visceral: deep internal pain receptors dull, heavy, aching pain occur over wide area, can cause referred pain Ex: labor, pancreatitis, cancer Radiating: arises in one site and extends to another (sciatic pain) Referred: arises in one site but is felt in a distant site (MI, appendicitis) Phantom: percieved as arising from a site that was surgically removed (amputation) Physical: cause of pain can be identified cancer vs. Non- cancer pain Psychogenic: cause of pain cannot be identified outdated term

Answer 8

Physiologic: sympathetic response (moderate and superficial) or parasympathetic responses (severe and deep) behavioral: grimacing, moaning, crying, restless, guarding Affective: stoicism, restlessness, anxiety, weeping, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness

Answer 9

Culture ethnic variable family, sex, gender, and age variables religious beliefs environment and support people anxiety, fatigue, and other stressors past pain experience and coping styles Patient- centered care is required!!!! be aware of bias!!!

Answer 10

Psychological, spritual, sociocutural characteristic of pain physiologic responses behavioral responses affective responses

Answer 11

patient verbalization and description of pain timing (onset, duration, pattern) location of pain (superficical, deep, referred, radiating) Intensity of Pain (severity-severe, moderate, mild) Periodicity: (continous, intermittent, brief, transient) Quality of Pain; (dull, stabbing, crushing, throbbing, sharp, burning, diffuse, shifting) Chronology of pain: Aggravating and alleviating factors (movement, positions drinking/eating, swallowing, stress, coughing, heat/cold) Physiologic indicators of pain behavioral responses effect of pain on activities and lifestyle

Answer 12

0-10 Numeric Rating Scale Adult Nonverbal Pain Scale Wong-Baker FACES Beyer Oucher pain scale CRIES pain scale FLACC scale COMFORT scale

Answer 13

the patient is the only person who should press the button to administer the pain medication when PCA is used monitor the patient for signs and symptoms of oversedation and respiratory depression keep diary of pain medications to prevent under and overuse monitor for potential side effects of opioid analgesics Safety: avoid drinking, operating machinery, alcohol, or other CNS depressants do not breastfeed without consulting provider

Answer 14

give medications orally if possible administer medications ATC rather than PRN adjust the dose to achieve maximum benefit with minimum side effects allow patients as much control as possible over regimen

Answer 15

S: sleep, easy to arouse: no action necessary 1: awake and alert; no action necessary 2: occasionally drowsy, but easy to arouse; no action necessary 3: frequently drowsy, drifts over to sleep during conversation; reduced dosage 4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone Naloxone (Narcan) can be used to reverse effects of respiratory depression

Answer 16

Step 1: nonopioid (+/- Adjuvant) Step 2: opioid for mild to moderate pain (+/- nonopioid, +/- adjuvant) Step 3: opioid for moderate to severe pain (+/- nonopioid, +/- Adjuvant)

Answer 17

Distraction (ambulation, deep breathing, visitors, TV, games, prayer, music, pet therapy) Humor Music Guided Imagery & relaxation (medication, yoga) Cutaneous stimulation (massage, TENS, heat, cold) Acupuncture hypnosis biofeedback therapeutic touch animal-faciliated therapy

Answer 18

Nonopioid Analgesics:(acetaminophen and NSAIDS) tylenol hepatoxic max- 4g/day NSAIDS long term: GI bleeding Opioids or narcotic Analgesics: (controlled substances: morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) - Side Effects: sedation, respiratory depression, N/V, constipation, urinary retention, altered mental processes, orthostatic hypotension, withdrawal/tolerance Adjuvant Drugs: anticonvulsants, antidepressants, multipurpose drugs

Answer 19

type of pain etiologic factors behavioral, physiologic, affective responses other factors affecting pain process

Answer 20

Nociceptive: type of Nociceptive pain - cutaneous -somatic -visceral Neuropathic: damage from abnormal or damaged nerve pain Ex: phantom limb pain, diabetic neuropathy pins and needles, burning, shooting, intense

Answer 21

Preoperative: beings with decision to have surgery, last until patient is transferred to operating room or procedural bed Intraoperative: begins when the patient is transferred to the OR bed until transfer to the post anesthesia care unit (PACU) Postoperative: last from admission to PACU or other recovery area to complete recovery from surgery and last follow-up health care providers visit

Answer 22

Urgency: elective, urgent, emergency Risk: Minor or Major Purpose: diagnosic, curative, preventable, ablative, palliative, reconstructive, transplantation, construtive

Answer 23

Anesthesia: loss of sensation in all or part of the body with or without loss General: administration of drugs by inhalation or intravenous route Moderate Sedation/analgesia: (conscious sedation/analgesia) used for short-term minimally invasive procedures Regional: anesthetic agent injected near a nerve or nerve pathway or around operative site Topical and local anesthesia: used on mucous membranes, open skin, wounds, burns

Answer 24

Induction: from administration of anesthesia to ready for incision Maintenance: from incision to near completion of procedure Emergence: starts when patient emerges from anesthesia and is ready to leave operating room

Answer 25

loss of consciousness Amnesia (loss of memory) analgesia (absence of pain) relaxed skeletal muscles depressed reflexes

Answer 26

description of procedure and alternative therapies underlying disease process and its natural course name and qualification of person performing procedure explanation of risks and how often they occur explanation that the patient has the right to refuse treatment or withdraw consent explanation of expected outcome, recovery, rehabiliation plan, and course of treatment

Answer 27

Living Wills: a legal document that expresses, in advance, a person instructions or preferences about future medical treatments particularly end of life care in the event the person loses capacity to make health care decisions Durable Power of Attorney for healthcare: a legal document that appoints a person (typically called a health care agent, but also a proxy, health care representative) to make decisions for the person n the event of incapacity (temporary or permanent) to make healthcare decisions Do Not Resuscitate (DNR)

Answer 28

elimination needs fluid and nutrition needs comfort and rest needs helping the patient cope

Answer 29

monitoring vital signs implementing deep breathing coughing incentive spirometry turning in bed every 2 hours ambulating maintaining hydration avoiding positioning that decreases ventilation monitoring responses to narcotic analgesics

Answer 30

every 10-15 minutes respiratory status (airway, pulse oximetry) cardiovascular status (blood pressure) temperature central nervous system status (level of alertness, movement and shivering) fluid status wound status Gastrointestinal status (nausea and vomiting) general condition

Answer 31

prevent wrong site, wrong procedure, and wrong person preoperative patient identification verification process marking the operative site final verification just prior to beginning the procedure, referred to as the time-out

Answer 32

Chemical: provides exact descriptions of medical composition (N-Acetyl-para-aminophenol) Generic: the manufacture who first develops the drug assigns the name, and then it is listed in the U.S pharmacopeia (acetaminophen) Trade: also known as brand or proprietary name. this is the name under which a manufacturer markets the medication (look for @ or TM) (tylenol, pandol, tempra) Classification: effect of medication on body system symptoms the medication relieves medications desired effects (analgesia, antipyretic, stimulants) medication forms: solid, liquid, other oral forms: topical, parenteral, forms for instillation into body cavities

Answer 33

the study of how medications enter the body are absorbed and distrubted into cells, tissue, or organs reach their site of action alter physiological function are metabolized exit the body

Answer 34

therapeutic effect: expected or predicted physiological responses adverse effect: unintended, undesirable, often predictable Side effect: predictable, unavoidable secondary effect Toxic effect: accumulation of medication in the bloodstream Allergic Reaction: unpredictable response to a medication; anaphylatic reaction Medication Interaction: when one medication modifies the action of another

Answer 35

standing or routine: administered until the dosage is changed or another medication is prescribed PRN: given when patient requires it Single (one-time): given one time only for specific reason Now: when a medication is needed right away; but not STAT STAT: given immediately in an emergency Prescription: medication to be taken outside of hospital

Answer 36

determining medication ordered are correct, assessing patient ability to self-administer, determining whether patient should recieve mediation at given time cosely monitoring effect cannot be delgated includes patient teaching nursing students cannot administer medications without supervision by a licensed RN

Answer 37

therapeutic range peak trough biological half-life plateau time-critical medications patient teaching

Answer 38

tablets, capsules, suspensions, exlixirs, lozenges Sublingual Administration: under tongue Buccal Administration: Cheek

Answer 39

Subcutaneous Injection: subcutanous tissue Intramuscular injection: muscle tissue Intradermal Injection: corium (under epidermis) Intravenous injection: vein Intra-arterial injection:artery Intracardial injection: heart tissue Intraperitoneal injection: peritoneal cavity Intraspinal injection: spinal canal Intraosseous injection:

Answer 40

through the patients eyes (preferences, values, and needs) History: Allergies, medications, diet history, patients perceptual or coordination problems patient current condition (some illness place pt. at risk for adverse medication effect) patients attiude about medication use factors affecting adherence to medication therapy patients learning needs, health literacy

Answer 41

through the patient eyes... partner with your patients response to medication ability to self care identify barriers to medication adherence Patient Outcomes: use knowledge of the desired effect and common side effects of each medication to compare expected outcomes with actual finding

Answer 42

6 Rights: 1. right medication 2. right dose 3. right patient 4. right route 5. right time 6. right documentation 11 Rights: medication patient dosage route time reason assessment documentation response educate refuse

Answer 43

A patient has the right to... To be informed about a medication To refuse a medication To have a medication history To be properly advised about experimental nature of medication To receive labeled medications safely To receive appropriate supportive therapy To not receive unnecessary medications To be informed if medications are part of a research study

Answer 44

Read the label. First check: when the nurse reaches for the container or unit dose package Second Check: after retrieval from the drawer and compared with the eMAR/MAR or compared with the EMAR/MAR immediately before poruing from the multidose container third check: before giving the unit dose medication to the patinet or when replacing the multi-dose container in the drawer or shelf

Answer 45

checking the identification bracelet validating the patient name (first identifier) validating the patient identification number, medical record number and/or birth date (second identifier) comparing with MAR asking patient to state his or her name if possible

Answer 46

check MAR with accuracy of the order know information about the medication that you plan to administer (action, purpose, normal dose, route, side effects, time of onset, peak, nursing implications perform assessment (review of lab values, pain, respiratory assessment, cardiac assessment prior to medication administer to ensure the patient is recieving the correct medication for the correct reason. Assess for contraindications ensure correct dosage calculation. Double check, have another nurse verify calculation gather medication from the pyxis (no-interuption zone) make sure medication is not expired and barcode is intact high alert medication needs a second nurse hand hyigene educate the patient about the medication before administering it, Answer questions regarding usage, dose, and special considerations use at least 2 patient identifers before administration scan patient bracelet check for allergies, type of reaction, severity of reactions scan medication position patient for proper administration of medication if oral medication, give with fluid ensure patient took medication, never leave in the patient room perform hand hygiene determine response to medication; complete assessment and/or vital signs check to make sure no adverse effects

Answer 47

report all medication errors patient safety is top priority, when an error occurs read all orders, instructions, and labels carefully ask questions if you do not understand do not allow anyone or anything to interupt you double check all calculations use at least 2 ways to identify patient identify and report system issues learn as much as you can about the medication you administer

Answer 48

verify that the tube location is compatible with medication absorption use liquids when possible if medication is to be given on an empty stomach; at least 30 min before or after feedings risk of drug-drug interaction is higher

Answer 49

Skin applications: use gloves and applicators; clean skin first use sterile technique if the patient has open wound follow directions for each type of medication Transdermal patch: remove old patch before applying new document the location of the new patch ask about patches during medication history apply a label to the patch if it is difficult to see document removal of the patch as well

Answer 50

spray drops tampons

Answer 51

avoid the cornea avoid the eyelids with droppers or tubes to decrease the risk of infections use only on affected eye never share medications

Answer 52

instill eardrops at room temperature have patient sit upright or lie on side straighten ear canal: adults pull auricle upward and outward Child: down and back use sterile solutions and aseptic technique check for eardrum rupture if patient has ear drainage never occlude the ear canal

Answer 53

suppositories, foam, jellies, creams applicators used (wash with soap and water) patient often prefer adminstering own vaginal medications and need privacy suppository insert 7.5-10cm (3-4 inches) stay supine for 5 minutes

Answer 54

Pressurized Meter-dose inhalers (pMDIs) need sufficient hand strength for use may be used with a spacer Breath Actuated metered-dose inhalers (BALs) release depends on strength of patient breath Dry Powered inhalers: (DPIs) activated by patient breath hold breath 5-10 seconds, release with pursed lips rinse mouth with corticosteroid inhale

Answer 55

irrigations cleanse an area, instill a medication, or apply hot or cold to injured tissue irrigations most commonly use sterile water, saline, or antiseptic solutions on the eye, ear, throat, vagina and urinary tract use aseptic techniques if there is a break in the skin or muscosa use clean technique when the cavity to be irrigated is not sterile, as in the case of the ear canal or vagina

Answer 56

accuracy is critical roll cloudy insulin, never shake (causes air bubbles- less accurate) verify with another nurse wipe top of vials with alcohol swabs trick to remember: RN or clear to cloudy administer within 5 minutes never mix lantus or levemir with other types of insulin

Answer 57

use a sharp-beveled needle in the smallest suitable length and gauge; position patient comfortably select proper injection site apply a vapocoolant spray or topical anesthetic divert the patient attention from the injection insert needle quickly and smoothly hold the syringe steady while needle remains in tissue inject medications slowly and steadily

Answer 58

administer into the adipose tissue layer just below the epidermis and dermis slower absorption from the IM injection use 3/8-5/8 inch, 25-27 gauge needle inject at 45-90 degree angle: for obese patient use a 90 degree angle small volumes not more than 1.5 mL do not massage site rotate sites

Answer 59

faster absorption than subcutaneous route many risks, so verify the injection is justified angle of administration: 90 degrees body mass index (BMI) and adipose tissue influence needle size selection Amounts: Adults: 2-5 mL (4-5 mL unlikely to be absorbed properly) children, older adults, thin patients: up to 2 mL small children and older infants: up to 1 ml) smaller infants: up to 0.5 mL

Answer 60

used for tuberculin screening or allergy testing tuberculin or small hypodermic needle 5-15 degrees with bevel of needle pointing up small bleb appears

Answer 61

not recommended because of proximity to sciatic nerve and major blood vessels large amount of subsutaneous tissue

Answer 62

safest for adults, children, and infant esp with large volumes recommended with volumes greater than 2 mL Volume: average 2-4 mL flex the knee and hip to relax muscle Needle size: Adult: 1.5 inches Child: 1/2-1 inch index finger, the middle finger, and the iliac crest form v-shaped triangle injection site is center of triangle

Answer 63

used for adults and children use middle third of muscle for injection often used for infants, toddlers, and children receiving biologicals

Answer 64

small volumes and immunizations Needle length: Adult 1-1.5 child: 1/2- 1 inch

Answer 65

z track method is recommended to minimize skin irritation by sealing the medication is muscle tissue zigzag path seals needle track medication cannot escape from the muscle tissue change needle before administering medication use a large muscle such as ventrogluteal muscle the needle remains inserted for 10 seconds to allow medication to disperse evenly rather than channeling back up the track of the needle release the skin after withdrawing the needle

Answer 66

snap off ampule neck aspirate medication into syringe using filter needle replace filter needle with an appropriate size needles or needless device administer needle

Answer 67

if dry, use solvent or diluent as needed inject air into vial label multidose vials after mixing refrigerate remaining dose if needed never put a dirty needle in a multi dose vial clean multidose vial with alcohol swab

Answer 68

a small (25-250 ml) IV bag or bottle connected to a short tubing line that connects to the upper Y port of a primary infusion line or to an intermiitent venous assess

Answer 69

Introduces a concentrated dose of medication directly into the systemic circulation Advantageous when the amount of fluid that a patient can take is restricted The most dangerous method for medication administration because there is no time to correct errors Confirm placement of the IV line in a healthy site Determine the rate of administration by the amount of medication that can be given each minute Make sure the site is healthy

Answer 70

Stimulus or referent sender or source of message (encoder) message itself medium or channel commication Receiver (decoder)

Answer 71

incivility bullying: horizontal violence nurse bullying negative communication between nurse and physician aggressive behavior organizational response to disruptive behavior

Answer 72

failure to perceive the patient as human failure to listen nontherapeutic comments and questions using cliches using closed questions using questions containing the words "why" and"how" using questions that probe for information using leading questions using comments that give advice using judgemental comments changing the subject giving false assurance using gossip and rumors using disruptive interpersonal behavior

Answer 73

group identity cohesiveness patterns of interaction decision making responsibilty leadership power

Answer 74

open-ended questions or comments closed question or comments validating questions or comments clarifying questions or comments reflective questions or comments sequencing questions or comments directing questions or comments

Answer 75

S: sit facing the client O: observe an open posture; keep arms and legs uncrossed to receive info L" lean toward the client E: establish and maintain intermittent eye contact R: relax

Answer 76

Verbal: (language ~words) Nonverbal (body language) facial expressions, touch, eye contact postur, gait gesture general physical appearance mode of dress and grooming sounds, silence (moaning, crying, gasping, sighing) electronic communication

Answer 77

developmental level gender sociocultural differences roles and responsibilites space and territorality physical, mental, and emotional state values environment

Answer 78

I'm Concerned I'm uncomfortable This is Unsafe

Answer 79

sit when communicating with a patient be alert and relaxed and take your time keep conversation as natural as possible maintain eye contact if appropriate use appropriate facial expressions and body gestures think before responding to the patient do not pretend to listen listen for themes in the patient comments use silence, therapeutic touch, humor appropriately

Answer 80

control the tone of your voice, know your face be knowledgeable about the topic of conversation be flexible be clear and concise avoid words that might have different interpretations be truthful keep an open mind take advantage of available opportunities

Answer 81

specific objectives comfortable environment privacy confidentiality patient vs task focus utilization of nursing observations optimal pacing

Answer 82

warmth and friendliness openness and respect empathy honesty, authenticity, trust non-judgemental caring competence

Answer 83

dispositional traits rapport builders

Answer 84

Orientation phase working phase termination phase

Answer 85

Anticoagulants: precipitate hemorrhage Diuretics: electrolyte imbalances, respiratory depression from anesthesia Tranquilizers: increase hypotensive effects of anesthetia agents Adrenal Steroids: abrupt withdrawal may cause cardiovascular collapse Antibotics in mycin group: respiratory paralysis when combined with certain muscle relaxants

Answer 86

Smoking: respiratory problems and poor wound healing Age; very young and older patient nutrition: increases need for nutrients, thin and obese patients often protein and vitamin deficient Obesity: Morality increaes due to reduction in ventilary and cardiac function Obstructive sleep apnea (OSA) Immunosuppresion: risk for infection after surgery fluid and electrolyte imbalance: hypovolemia Postoperative nausea and vomiting (PONV) 30% can have PONV, can lead to pulmonary aspiration, dehydration, arrhythmias, pull apart suture

Answer 87

developmental level medical and surgical history medication history nutritional status use of alcohol, illict drugs, or nicotine activiites of daily living and occupation coping patterns and support system sociocutural needs

Answer 88

Health history (medical, surgical, developmental, implants, nutrition, alcohol/drugs, ADLs) physical exam risk factors and allergies medication and treatments pre-operative blood work and testing teaching and psychosocial needs determine postsurgical support and referrance

Answer 89

reduces length of hospital stay and cut cost reduces stress for the patient may require additional teaching and home care services for certain patient older patients, chronically ill patient, patint with no support system

Answer 90

hemorrhage shock thrombophlebitis deep vein thrombosis pulmonary embolus atelectasis pneumonia surgical site complications

Exam 3 Flashcards

(115 cards)