NURS 310 EXAM 5 Flashcards Preview

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Flashcards in NURS 310 EXAM 5 Deck (89):
1

Best restorative sleep

Rapid eye movement sleep

(REM sleep)

2

should nap for how long?

30 minutes and no longer than hour and 30 min

3

who needs the least amt of sleep?

elderly

4

how much sleep does elderly need?

6-8 hours.

5


Developmental Stages that affect sleep

Motivation
Culture— Mexicans have siestas
Lifestyle
Habits
Environmental Factors
Psychological Stress
Illness
Medications

6

difficulty falling or staying asleep

insomnia

7

too much sleep

hypersomnia

8

fall asleep anywhere

narcolepsy

9

stop breathing when you sleep

sleep apnea

10

peoples whose legs actually move when they sleep

restless leg syndrome

11

the sensory experience includes

reception and perception

12

reception

reception.

13

perception

perception.

14

Stimuli

stimuli.

15

impulse conduction

impulse conduction.

16

whose at risk for sensory deprivation?

elderly

17

Whose at risk for sensory overload?

kids

18

Factors Affecting Sensory Stimulation

Developmental Stage
Culture
Stress
Medication and Illness
Lifestyle and Personality

19

assessment of sensory experience

nursing history
mental status
physical examination

20

what do nurses check on the physical examination?

visual
auditory
gustatory
olfactory
tactile

21

taste sense

gustatory

22

disturbed sensory perception example?

hallucinations

23

deprivation prevention interventions

teach wellness care & adjust environmental stimuli

24

Deprivation Prevention Interventions (LONG)

-Encourage use of eyeglasses and hearing aids
-Communicate frequently about current events
-Provide telephone, radio, TV, clock, and calendar
-Provide pictures, sculptures, wall hangings
-Have visitors bring plants and flowers. not in ICU or isolation rooms.
-Have a resident pet (fish, bird, cat)
-Have sheepskin pillows, silk scarfs, soft blankets
-Offer back massages, hair care, foot soaks
-Encourage activities with others (bingo, card games, dominos)
-Encourage crossword puzzles or scrabble
-Encourage sitting next to a window or a trip to the atrium for a change in environment
--Encourage singing, humming, whistling for self-stimulation

25

Sensory overload prevention?

-Offer sunglasses
-Offer earplugs
-Keep a wound dressing dry and clean
-Provide rest intervals free of interruptions
-Limit visitors
-Explain sounds in the environment

26

How would you meet the needs of a visually impaired patient?

Orient
Clear pathways
Organize
Keep bed low
Call light
Ambulation

27

Hearing impaired patient

Orient to your presence
TV or radio
Hearing aids
Talk to the patient
Write ideas down
Demonstrate or pantomime

28

confused patient?

-Address the patient
-Identify time and place
-KISS—keep it simple stupid.
-Fill the space
-Environmental stimuli
-Use objects from the past

29

unconscious patient

-Speak to the patient
-Be careful – hearing is usually the last sense lost
-Before you touch them
-Environmental noises

30

what do you do before touching an unconscious patient?

tell them you are going to touch them

31

pain for a short amount of time

acute

32

pain longer than needed

chronic

33

skin pain

cutaneous

34

pain in tendons, ligaments, bones, blood vessels, & nerves

deep somatic

35

pain in localized organs

visceral

36

.

radiating

37

feels pain in different area than what is affected

referred

38

uncontrollable pain

intractable

39

diabetic pain

neuropathic

40

pain in limb that is not there

phantom pain

41

-pain synapses in dorsal horns of spinal cord.

-communication gates control

-large nerve fibers out-signal smaller nerve fibers.

-may be how electrical, mechanical stimulation, heat and pressure can relieve pain.

gate control theory

42

Amount of pain stimulation a person requires in order to feel pain

pain threshold

43

Factors Affecting The Pain Experience

-ethnic and cultural
-family, gender, age variables
-religious beliefs
-environment and support people
-anxiety and other stressors
-past pain experiences

44

what does OLD CART stand for?

onset
location
duration
characteristics
aggravating
radiating
treatments

45

non pharmacologic measures

-Remove cause of pain
-Alter factors affecting pain tolerance
-Engage in distraction
-Use humor—be appropriate with this!
-Use music as a distraction
-Assist with guided imagery
-Teach active relaxation techniques
-Cutaneous stimulation
-Acupuncture

46

type of medicine that won't put you to sleep

non-opiods

47

will put you to sleep

opiods

48

makes it work better.

ex: heat or cold.

works along with it

adjuvant drugs

49

don't wait until the patient is in ___ to begin treatment

pain

50

_____ pain is easier than ____ pain once it has occurred.

preventing; treating

51

cancer and chronic pain treatment regimens

-Give medications in the least painful mode

-Give pain medications around the clock

52

set up to give med every x amount of hours

basal

53

when you push the button to give yourself another hit of medicine

bolus

54

people use less pain med in this method

patient controlled analgesia

55

emergency surgerys

appendectomy
MVAs
torn meniscus

56

elective surgery

plastic surgery

cataracts

dental implants

57

getting the patient marked up, labs done, making sure their prepared.

preoperative

58

begins in OR and lasts til post op or anastesia unit.

intraoperative

59

admission to recovery room and until VS & 10 counts are counted

postoperative

60

lower % of body water. Fluid and electrolyte imbalance. Changes in liver and kidney fxn. don’t respond well to medicine. poor nutrition = poor wound healing. Hearing aids and dentures, stents, mitral valve prolapse,

elderly

61

have limited fluid reserves, so they can’t stay warm in the cold OR room. Prone to hypothermia and hyperthermia. Kidney’s can resist the medicine that’s given.

infants

62

in the preoperative phase what should you assess for?

age
infant and elderly at greater risk
nutritional status
general health status
medications
mental state

63

open up

dehiscence

64

bowel comes out

evisceration

65

malignant hyperthermia treatment

sodium dantrolene

66

cardiovascular problems in surgery:

Increased risk for hemmorhage, over hydration with IV fluid,
the stomach empties every 2-4 hours.

67

how often does the stomach empty?

every 2-4 hours

68

physical assessment in the preoperative phase?

-check that the database is recorded.
-report any abnormal findings to the attending physician
-check diagnostic testing that has been completed
-be sure testing has been done
-evaluate finding and report any abnormal findings to the physician
-assure that results are on the patient's chart
-provide optimal nutrition and hydration status (NPO)

69

respiratory pre operative teaching?

teach coughing exercises, deep-breathing exercises, and incentive spirometer use.

70

how do you manage pain after surgery?

ask patient to rate their pan 0-10

71

WHY do you manage pain after surgery?

pain can delay healing.

72

do these to increase venous return from the lower extremities--to prevent thrombophlebitis and emboli

leg exercises

73

teach your patient about what post-operative machines and equipment?

pulse ox--on finger
cardiac monitor
artificial airway
intravenous infusion

74

what other things should you do before a patient goes to surgery?

-answer all their questions
-apply anti-embolism stockings
-insert indwelling catheter if ordered and needed
-Prepare incisional site as ordered.
-provide comfortable environment
-remove prosthesis (glasses, dentures, contacts)
-make sure pt. has armband

75

paperwork before surgery?

-current vital signs
-notify pt. if they can/can't consume food or fluids
-informed consent is signed
-advanced directives are on the chart
-encourage pt. to empty bowel/bladder just before surgery
-have pt. leave valuables at home, or give them to a family member, or call HA security and give it to them.

76

Complete pre-op checklist

& administer preoperative medications as ordered upon call from the OR

preoperative phase

77

Holding area
-ID pt.
-assess emotional/physical status
-verify info on pre-op checklist
-perhaps start IV
-perhaps give pre-op meds

intraoperative phase

78

personnel in OR

scrub nurse
circulating nurse
registered nurse first assistant

79

PACU

post anesthesia care unit

80

what to asses in PACU?

-respiratory status
-cardiovascular status
-LOC
-presence of protective reflexes (gag, cough)
-activity
-fluid status
-condition of operative site
-drainage
-discomfort
-safety

81

place bed in lowest position with top side rails up and call bell in patient's reach.

postoperative phase

82

assess what in post-op

-vital signs
-LOC
-post op care
-hypo/hyperthermia
-drainage
-assess dressing
-assure that pts. tubes are patent and note amt of drainage in collection devices
-check IV rate of infusion and amt. remaining in bag
-assess pain--TREAT IF NEEDED

83

monitor VS how often in post op phase?

every 15 minutes for 1 hour

every 30 min for 2 hours

every hour for 4 hours

every 4 hours

84

how do you promote optimal respiratory fxn in your pt. in post op phase?

-coughing and deep breathing
-incentive spirometer
-monitor O2 sat
-change position every 2 hours
-administer O2 if needed
-maintain adequate circulation
-anti-embolism socks or hose are in place
-leg exercises and ROM
-assess elimination status

85

how would you assess elimination status?

measure I&O
offer bedpan on a regular basis
If catheter in place--assess amount and color

86

how would you assess elimination status?

measure I&O
offer bedpan on a regular basis
If catheter in place--assess amount and color

87

Promote optimal nutrition and gastrointestinal function

 Assess for peristalsis
 Assist with diet progression
 Clear to full liquids to soft to regular
 Encourage fluid intake
 Medicate for pain or nausea prior to eating times

88

-Promote wound healing
-Perform wound care as ordered by the physician
-Assess for signs of infection
-Allow rest periods for the patient
-Offer emotional and spiritual support

Postoperative Phase

89

what are you witnessing when a patient signs a consent?

the signature only. (informed consent)


not that they understand everything