Exam 3 Flashcards
(156 cards)
1
Q
Name the six defense mechanisms.
A
- repression
- denial
- sublimation
- regression
- projection
- displacement
2
Q
repression
A
- unconscious
- employed by ego
- keeps disturbing/threatening thoughts from becoming conscious
3
Q
denial
A
- blocking external events from awareness
- refusal to experience an overwhelming circumstance
4
Q
projection
A
attributing one’s unacceptable thoughts/feelings/motives to another person
5
Q
displacement
A
satisfying an impulse (e.g. aggression) with a substitute object
6
Q
regression
A
movement back in time psychologically when faced with stress
7
Q
sublimation
A
satisfying impulse (e.g. aggression) with a substitute, but in a socially acceptable way
8
Q
Name the three stress-induced psychological responses.
A
- crisis
- burnout
- post-traumatic stress disorder (PTSD)
9
Q
post-traumatic stress disorder
A
- begins with acute stress disorder
- delayed onset longer than 4 wks
- persists longer than 1 mo
- pt experiences flashbacks
10
Q
burnout
A
exhaustion of physical or emotional strength, and sometimes physical illness usually as a result of prolonged stress or frustration
11
Q
crisis
A
condition characterized by unusual instability caused by excessive stress
12
Q
Name the five categories of stress.
A
- distress
- eustress
- developmental
- situational
- adventitious
13
Q
distress
A
- damaging and can threaten health
- physical or mental pain or suffering
14
Q
eustress
A
- Psychological stress that affects performance in a positive way
- e.g., more alert, more aware of surroundings, or more enthusiastic
- protective
15
Q
developmental stress
A
response to life changes (e.g. graduation, role changes, etc.)
16
Q
situational stress
A
stress resulting from major life events such as trauma, severe illness, job change, etc.
17
Q
adventitious stress
A
stress resulting from major events such as natural disasters and crimes of violence
18
Q
How is physiological adaptation controlled?
A
The SNS (sympathetic nervous system) tells the adrenal medullae to release catecholamines, which cause reactions in multiple body systems
19
Q
physiological adaptation
A
fight-or-flight response
20
Q
What effects does the fight or flight response have on the body?
A
physiological adaptation raises:
- HR
- RR
- BP
- blood sugar
21
Q
General Adaptation Syndrome (GAS)
A
- Hans Selye’s description of the stress response
- “stress syndrome”
- has three stages:
- alarm/compensation: fight or flight
- resistance: energy in short supply
- exhaustion/decompensation: energy depleted
22
Q
Name and describe Selye’s three stages of GAS.
A
- alarm/compensation: fight or flight response
- resistance: energy in short supply
- exhaustion/decompensation: no longer able to maintain response to stressor; energy depleted
23
Q
local adaptation syndrome
A
- localized response to stress involving specific body part, tissue, or organ
- short-term attempt to restore homeostasis
- two types:
- reflex pain response
- inflammatory response
24
Q
Name and describe the two types of local adaptation syndrome.
A
- reflex pain response:
- localized response of CNS to pain
- protects from further damage
- involves sensory receptor, sensory nerve, effector muscle
- inflammatory response:
- damaged cells release histamine, prostaglandins, etc.
- capillaries leak fluid into tissues
- edma, erythema, warmth
25
factors affecting body temperature
* age
* hormonal changes
* exercise, activity
* dehydration
* illness and injury
* recent food or fluid intake
* smoking
* circadian rhythm
* stress, emotions
* environmental conditions
26
thermoregulation
* process of **maintaining** a stable body **temperature**
* heat loss and production controlled by **hypothalamus**
27
What is body temperature?
the **difference** between **heat produced** via metabolism and **heat lost** to the environment
28
What body systems help regulate body temperature?
**nervous** and **cardiovascular**
29
Name the six sites for measuring core temperature and three sites for surface temperature.
* core:
* rectum
* tympanic membrane
* temporal artery
* pulmonary artery
* esophagus
* urinary bladder
* surface:
* skin
* mouth
* axillae
30
guidelines for oral temp measurement
* contraindicated in
* mouth breathers
* pts with trauma to face or mouth
* expected: 96.8 to 100.4F (36 to 38C)
31
guidelines for measuring temperature rectally
* contraindicated in pts with
* diarrhea
* low platelet count/bleeding precautions
* rectal disorders
* expected: 0.9F (0.5C) higher than oral and tympanic
32
axillary temperature measurement variance
0.9F (0.5C) **lower** than oral and tympanic
33
How does a temporal artery temperature differ from other sites?
* close to rectal
* nearly 1F (0.5C) higher than oral
* 2F (1C) higher than axillary
34
What affects tympanic membrane temperature measurement?
excess earwax
35
How do we determine if a pt's temp is elevated?
compare to baseline
36
How does age affect thermoregulation?
* newborns
* large surface-to-mass ratio
* lose heat rapidly to environment
* expected: 97.7 to 99.5F
* older adults
* loss of SQ fat
* lower body temp, feeling cold
* expected: 95.9 to 99.5F (35 to 36.1C)
* temp can take longer to register on thermometer
37
pyrexia
* fever
* \> 100F (37.8C)
* important defense mechanism
* results from introduction of endogenous or exogenous pyrogens to bloodstream
* s/sx:
* pt may feel hot
* chills
* sweating
* rashes
* organomegaly
* painful joints
* murmurs
38
FUO
fever of unknown origin
39
febrile
having a fever
40
afebrile
* without a fever
* apyretic
41
hyperthermia
* unusually high fever
* nursing interventions
* prevent shivering
* remove cooling devices if shivering begins
42
heatstroke
* s/sx:
* body temp of 104F or higher
* headache
* numbness and tingling
* confusion preceding sudden onset of seizures, delirium, or coma
* tachycardia
* rapid RR
* increased BP followed by hypotension
* hot, dry, red skin
* can cause
* neurological damage
* multiple organ system failure
* death
43
heat exhaustion
* **acute** reaction to **hot**, **humid** environment
* **excess fluid loss** from the body
* s/sx: profuse **sweating**, **dizziness**, **nausea**, **headache**, and profound **fatigue**
44
shivering
* systemic response to cold to increase head production
* increases energy demand
45
malignant hyperthermia
* autosomal dominant disease marked by skeletal muscle dysfunction after exposure to some anesthetics
* temps can exceed 105°F (40.5°C)
* may be fatal
46
hypothermia
* core temp below normal
* extended exposure to cold, sometimes with frostbite
47
pain
* **unpleasant** sensory experience associated with **actual** or **potential** **tissue** **damage**
* can have **destructive** effects
48
How do we measure pain?
patient report
49
How is pain classified?
* origin
* cause
* duration
50
superficial pain
arises from superficial structures (skin, SQ tissues)
51
visceral pain
* comes from internal organs
* can cause referred pain
52
somatic pain
pain in joints, bones, muscles, skin, or connective tissue
53
referred pain
pain felt in one part of the body that originates from damage in another part of the body
54
phantom pain
pain that feels like it's coming from a body part that's no longer there
55
psychogenic pain
* pain disorder associated with psychological factors
* pain may not match symptoms/physical condition
56
nociceptive pain
"normal" transmission of pain: somatic, cutaneous, visceral
57
neuropathic pain
* caused by dysfunction in nervous system or nerve damage
* sx
* shooting pains
* tingling
* numbness
* pain with normal touch
58
pain origin classifications
* superficial
* visceral
* somatic
* radiating/referred
* phantom
* psychogenic
59
classification of pain by cause
* nociceptive
* neuropathic
60
classification of pain by duration
* acute
* chronic
* intractable
61
acute pain
* short duration (≤ 6 mos)
* sudden trauma, surgery, ischemia, inflammation
* usually obvious cause
* serves protective function, unless prolonged
* usually reversible
* mild to severe
* may be accompanied by anxiety and restlessness
* when unrelieved:
* increase morbidity/mortality
* prolong hospital stay
62
chronic pain
* ≥ 6 mos (or 3 mos)
* can be idiopathic
* usually begins gradually and persists
* no useful function
* more difficult to treat
* often accompanied by quality-of-life and functional adverse effects
* increased health care needs
* increased dependence on others
* financial burden
* fatigue
* depression
63
intractable pain
* chronic
* highly resistant to relief
64
transduction
activation of nociceptors by stimuli
65
transmission
conduction of pain message to spinal cord
66
pain threshold
point at which a person feels pain
67
pain tolerance
amount of pain a person is willing to bear
68
pain modulation
* occurs in spinal cord
* causes muscles to contract reflexively
* moves body part away from painful stimuli
69
factors that affect the pain experience
* prior experiences
* fatigue
* genetic sensitivity
* age
* emotions (anxiety, fear)
* support systems
* coping styles
* culture
* communication skills
* cognitive function
* contributing illnesses
70
assessing pain
* verbal: get complete Hx of pain
* **O**nset
* **L**ocation
* **D**uration
* **C**haracter
* **A**ssociated symptoms
* **R**elieving/aggravating factors
* **T**ime
* **S**everity
* nonverbal
* elevated HR, BP
* crying
* moaning
* grimacing
* guarding
71
effects of pain on pt
* behavioral
* verbalization
* vocal response
* facial/body movements
* social interaction
* ADLs
* physical deconditioning
* sleep disturbances
* sexual relationships
* ability to work (outside/inside home)
72
pain scales
* numeric rating scale (NRS)
* simple descriptor scale
* Wong-Baker FACES scale
* visual analog scale
* FLACC scale
73
FLACC
* **F**ace
* **L**egs
* **A**ctivity
* **C**ry
* **C**onsolability
74
risk factors in pain management
undertreatment
* cultural/societal attitudes
* lack of knowledge
* fear of addiction
* exaggerated fear of respiratory depression
* populations at risk
* infants
* children
* older adults
* pts with substance use disorder
75
undertreatment of pain
* serious health care problem
* can lead to physiological and psychological concerns
76
physiological effects of unrelieved pain
* prolonged stress response
* increased HR, BP, O2 demand
* decreased GI motility
* immobility
* decreased immune response
* delayed healing
* unrelieved acute can lead to chronic
77
hyperalgesia
heightened sense of pain
78
allodynia
condition in which pt **experiences pain** after experiences that are **not usually painful**
79
non-pharmacological pain management treatments
* cutaneous stimulation
* transcutaneous electrical nerve stimulation (TENS)
* acupuncture
* acupressure
* massage
* hot or cold therapy
* immobilization and rest
* cognitive-behavioral
* distraction: ambulation, deep breathing, games, TV
* relaxation: meditation, yoga
* guided imagery
* hypnosis
* therapeutic touch
* humor
* journaling
80
What kinds of therapies an effective pain management plan include?
pharmacological and non-pharmacological
81
gate control theory
gating mechanism in spinal cord allows pain signals to reach brain
82
heat therapy
* increases blood flow by **dilating** blood vessels
* best for **chronic** pain, **dull** and **achy**
* leads to increased **flexibility** and **mobility** in muscles and joints
* **dry** or **moist**: heating pad, hot pack, steamed towel, steam bath
83
cold therapy
* reduces blood flow by constricting blood vessels
* use **within** **72 hrs** of **acute** injury
* **reduces inflammation** and **pain**, aiding healing
* ice packs, frozen gel packs, ice baths
84
pharmacological treatments for pain
* non-opioid analgesics: for mild to moderate pain
* NSAIDs
* acetaminophen
* opioid analgesics: for moderate to severe pain
* IV, transdermal, epidural routes
* patient-controlled analgesia (PCA) pump
* monitor for adverse effects
* adjuvant analgesics (coanalgesics): enhance effects of opioids; useful for neuropathic pain
85
adverse effects of opioids
* sedation
* respiratory depression
* orthostatic hypotension
* urinary retention
* N&V
* constipation
86
non-opioid analgesics
* for mild to moderate pain
* NSAIDs
* acetaminophen
87
opioid analgesics
* for moderate to severe pain
* IV, transdermal, epidural routes
* patient-controlled analgesia (PCA) pump
* monitor for adverse effects
88
adjuvant analgesics (coanalgesics)
* enhance effects of opioids
* help alleviate other manifestations that aggravate pain
* useful for neuropathic pain
* includes
* anticonvulsants
* antianxiety agents
* tricyclic antidepressants
* anesthetics (lidocaine)
* antihistamine
* glucocorticoids
* antiemetics
* bisphosphonates and calcitonin (for bone pain)
89
pharmacological management of chronic pain
* long-acting or controlled-release opioid (including transdermal)
* administer around the clock instead of PRN
90
Joint Commission pain policy
* pain is **fifth vital sign**
* document
* pain **assessment**
* follow-up within **1 hr of PO** pain med admin
* reassess in **30 min for IV** pain med
* **goal** should be **0-3** on 0-10 scale
* effectiveness determined by pt
91
administering pain meds
* separate Rx's can be written for mild, moderate, or severe
* use judgment to pick Rx based on pt data
92
STAT Rx for pain
must be given **within 30 min**
93
nursing action for uncontrolled pain
if pain isn't controlled by Rx's, notify provider
94
placebo
* any med, procedure, etc. that produces an effect on the pt because of intent, not physical or chemical properties
* appropriate in research (informed consent)
* NEVER give placebo to pt
* contact supervisor if you're told to give a placebo
95
pain center
treat pts on inpatient or outpatient basis
96
palliative care
goal: live life fully with an incurable condition
97
hospice care
* end-of-life care focused on comfort
* ANA supports aggressive treatment of pain and suffering even if it hastens death
98
allopathy
* conventional western medicine/treatment
* treats pathologies and symptoms
99
holism
* treats whole person
* preventative strategies
* lifestyle changes
* optimal wellness
100
modality
* method of treating a disorder
* traditional: abx, surgery
* holistic
* complementary: used **with** traditional
* alternative: used **instead of** traditional
101
integrative healthcare
encompasses all treatment modalities
102
CAM categories
* whole medical systems (traditional Chinese, homeopathy)
* biological and botanical (diets, herbs, probiotics)
* mind-body therapies (acupuncture, meditation)
* energy therapies (reiki, therapeutic touch, magnet therapy)
* movement therapies (pilates, dance)
103
practitioners of complementary and alternative medicine
* acupuncture
* acupressure
* homeopathic
* naturopathic
* chiropractic
* massage
* biofeedback
* therapeutic touch
104
natural products and herbal remedies
* natural: herbal medicines, minerals and vitamins, essential oils, dietary supplements
* herbal: plant sources; oldest form of medicine
* not regulated by FDA
* commonly used substances can have interactions with prescription meds
105
aloe
used for wound healing
106
chamomile
* anti-inflammatory
* calming
107
echinacea
enhances immunity
108
garlic
inhibits platelet aggregation
109
ginger
antiemetic
110
ginkgo biloba
improves memory
111
ginseng
increases physical endurance
112
valerian
* promotes sleep
* reduces anxiety
113
nursing actions for CAM
* understand therapies and safety precautions
* be receptive
* identify pt's needs for CAM, values, preferences
* incorporate CAM into care plan
* evaluate pt's responses to CAM
* determine possible interactions with Rx meds and therapies
114
pre-op care
* from the time a pt is scheduled for surgery until care is transferred to OR
* assessment of risk factors
* thorough assessment of pt's physical, emotional, psychosocial status
115
reasons for surgery
* diagnostic
* curative
* restorative
* palliative
* cosmetic
116
urgency of surgery
* elective: nonacute problem
* urgent: prompt intervention required
* emergent: immediate intervention, life-threatening
117
degree of risk of surgery
* minor: no significant risk, often local anesthesia
* major: greater risk; longer and more extensive
118
extent of surgery
* simple: only affected areas involved
* radical: extensive beyond obviously involved area; finding root cause
* minimally invasive (MIS): endoscopy
119
Whose responsibility is it to obtain consent before surgery?
the provider's
120
What information can the nurse discuss with a pt before surgery?
clarification of info already discussed by the provider
121
What is the nurse's role in obtaining consent?
* witness signing of forms
* ensure client is legally capable of providing consent
* pre-op nurse must verify informed consent is complete/witnessed (notify provider and nurse manager)
* make sure surgical site is marked by surgeon
122
informed consent
* required for
* surgery
* invasive procedures
* things requiring sedation or anesthesia
* radiation
* anything that increases risk for complications
123
risk factors for surgery-related complications
* obstructive sleep apnea
* pregnancy
* respiratory dz
* CV dz
* DM
* liver, kidney dz
* endocrine disorders
* immune system disorders
* coagulation defect
* malnutrition
* obesity
* some meds
* substance use
* family Hx
* allergies
* advanced age
124
pre-op assessment
* detailed Hx
* allergies
* anxiety level
* baseline data
* venous thromboembolism (VTE) risk
125
risk factors for surgery complication
* UA
* blood type and cross match
* CBC
* pregnancy test
* clotting studies
* electrolyte levels
* creatinine and BUN
* ABGs
* CXR
* 12-lead ECG
126
pre-op pt education
* understand purpose/effects of pre-op meds
* be aware of post-op pain control techniques
* splinting, coughing, deep breathing, incentive spirometry
* ROM exercises and early ambulation
* antiembolism stockings and SCDs
* purpose of invasive lines during and after surgery
* post-op diet
* pain scale
* avoid smoking, alcohol, illicit drug use
127
intraoperative care
from the time pt enters OR to time of transfer to PACU or ICU
128
risks to pt in intra-op period
* infection
* skin breakdown
* anxiety
* ineffective thermoregulation
* injury related to positioning
129
members of the surgical team
* surgeon
* surgical assistant
* anesthesia providers
* perioperative nursing staff
* holding area nurses
* circulating nurses
* scrub nurses and/or techs
* specialty nurses
130
circulating nurse duties
coordinate, oversee, conduct pt care while in OR
131
What are the three zones of an OR?
* unrestricted
* semi-restricted
* restricted
132
What conditions exclude an employee from participating in a surgery?
* open wound
* cold
* infection
133
attire for OR
* change in locker room
* wear hospital-laundered scrubs
* cover all hair and facial hair
134
Who performs a surgical scrub before surgery?
* surgeon
* assistants
* scrub nurse
135
counting in the OR
performed before, during, at first layer of closure and immediately before final closure
136
What is considered sterile after gowning and gloving?
* front of gown from chest to level of sterile field
* sleeves from 2 inches above elbow to cuff
* NOT back of gown
137
What responsibilities does every member of the surgical team have?
* ID of pt
* assessment
* med record review (advance directives, DNR)
* surgical consent verification
* validate correct site/side with pt (time out if not)
* allergies and previous reactions to anesthesia or transfusions
* autologous blood transfusion
* lab and diagnostic test results
* Hx and physical exam: any threats to pt safety
138
contraindications for receiving propofol
allergies to eggs and soybean oil
139
3 phases of general anesthesia
* induction: IV access, admin of pre-op meds, securing of airway
* maintenance: performance of surgery, airway maintenance
* emergence: completion of surgery, removal of assistive airway devices
140
What should you do if perioperative hypotension occurs?
* lower HOB
* give IV fluid bolus
* monitor
* notify surgeon and anesthesiologist of abnormalities
141
anesthesia complications
* malignant hyperthermia
* anesthetic toxicity
* unrecognized hypoventilation
* intubation problems
* anesthesia awareness
142
What drug is used to counteract malignant hyperthermia?
dantrolene (Dantrium)
143
what to do if MH occurs
* help stop surgery
* give IV dantrolene
* give 100% O2
* get ABGs and potassium level
* infuse iced IV normal saline
* apply cooling blanket
* apply ice to axillae, groin, neck, head
* iced lavage
* monitor cardiac rhythm and treat dysrhythmias
* transfer to ICU
144
What type of drug prolongs the effects of and reduces risk of systemic toxicity with local anesthetics?
vasoconstrictor (usually epinephrine)
145
How often do you document vitals after moderate sedation?
every 15-30 min until pt is awake, alert, and oriented with VS at baseline levels
146
nursing duties in PACU
* monitor
* respiratory, circulatory status
* LOC, VS, O2 sat: every 15 min until stable
* examine surgical area
* heated blankets for hypothermic pt
* assess return to consciousness (general)
* assess return of motor function (local/regional)
* discharge from unit
147
expected O2 sat after surgery
\> 92%
148
hypervolemia s/sx
* bounding pulse
* SOB
* orthopnea
* crackles
149
hypovolemia s/sx
* anxiety
* restlessness
* tachycardia
* tachypnea
* cool, clammy skin
* delayed cap refill
* decreased UOP
150
opioid overdose interventions
* give naloxone hydrochloride 1-2 mg IV
* repeat every 2-3 min up to 10 mg depending on response
* maintain airway
* O2 if hypoxic
* get suction ready in cause of vomiting
* DO NOT leave pt alone
* monitor every 10-15 min for 1 hr until stable
* assess for naloxone SE
151
post-op pt is NPO until what functions occur
* gag reflex returns
* peristalsis resumes (flatus and/or BM)
152
surgical site drainage progression
1. sanguineous
2. serosanguineous
3. serous
153
When do you monitor wound drains?
when taking VS
154
gastroparesis
delayed stomach emptying
155
criteria for discharge
* pt can
* take fluids orally and safely
* ambulate to bathrom with assistance
* significant other to accompany pt
* Aldrete score 8-10
* stable VS
* no evidence of bleeding
* return of reflexes: gag, cough, swallow
* minimal to moderate wound drainage
* UOP ≥ 30 mL/hr
156
