exam 3

What is the most problematic effect of opiods

respiritory depression and sedation,

others: orthostatic hypotension nasuea vomitting, urinary retention constipation

what is the priority with opioid use related to abc and should be monitored?

respiritory depression affecting pts breathing, hypoxia

pulse oximetry

difference between objective and subjective findings related to opiod use

objective: nurse observed: respiratory rate, sedation, consciousness, pulse

subjective: pt reports: dizziness nausea, vomitting constipation

How should a pt store narcotics?

Opioids, in particular, must be locked away and should be stored in their original packaging.

What are non-verbal pain cues?

objective data: what we observe because pt cannot speak

Non verbal pain scale (NVPC): rates pain on a scale of 1-5 of different levels

1. facial expressions: clenching jaw, eye movemnets

2. pt physical actvitity:bodylanguage touching painful body part, rubbing, clucthing body part

3. guarding(voluntary contraction or stiffness of the body when in pain)

4. Vitals signs

5. Respiritory rate

6. sounds: crying moaning

   • territoroality, personal space: can make pt percieve a threat

Subjective findings for pain

pain scale score, along with quantity and quality of pain

Objective findings for pain

grimacing, guarding, crying

What is chronic pain?

Lasting 6+months and recurs, not protective

Physilogical: do not alter vitals

psychsocial: leads to disability

relief: long acting/controlled release opioids analegesics

what is acute pain

temporary pain, direct, protective, pain resolves w/tissue healing

physiological: tachycardia. hypertension, anxiety, diaphoresis(sweating) , muscle tension

behavior responses: grimacing, moaning, guarding, flenching

relief: treatment of acute pain problem

what is nociceptive pain

pain arising from damage or inflammation of tissue

characteristics: throbbing, aching, localized

relief: responds to opioids and non opioids

types:

-somatic: bones joints muscle skinn connective tissue

-visceral: organs stomach intestine

-cutaneous: skin or subq tissue

what is neuropathic pain

abdominal or damaged pain in nerves

ex: phantom limb pain(in amputee) pain below level of spinal cord injury and diabetic neuropathy

characteristics: intense shooting burning pain (pins and needles)

relief: adjuvnat meds, antidepressants, antispasmodic agents, skeletal muscle relaxants

what does PQRST stand for and what are you assessing with each letter?

Precipitating cause: What were you doing when the pain started?

Quality:Describe what your pain feels like.”

Region:Show me the location where you are experiencing pain.”

Serverity: On a scale of 1 to 10, how would you rate your pain?

Timing: “When did your pain first begin? Have you experienced this pain before?”

what are symtoms of fight or flight related to stress

elevated: BP, HR, mental alertness, increased secretion of epinephrine and norepinephrine, increased blood flow to muscles

what are teachings for stress

regular excercise

healthy diet

time management

personal resilance

rest relaxation methods:yoga

alternatives: journaling massage meditation

how can stress affect the body

impairs and weakens the immue system

hypertension

depression

autoimmune disorders

what can happen to a pt in a stressful state for long periods of time?

exhaustion stage: client cannot adapt to stress resulting in recovery or death

• prolonged exposure to stress may result in illness or disease

physiological type of stress vs psychological stress

physiological: Physiological stressors are generally associated with injury or illness, such as exposure to extreme temperatures, trauma, injury, illness, or pain. The body’s reaction to acute physiological stress is immediate and necessary for survival. Chronic physiological stress can result in debilitating conditions.

psychological: psychological stressor is an event, situation, comment, condition, or interaction that an individual interprets as negative or threatening. Common psychological stressors include work or academic pressures, financial difficulties, change in marital status, or being a victim of a natural catastrophe.

four interventions the nurse can take to assist the client in coping with stress

be empathetic

identify strengths and aibilities

encoruage pt to use previous coping methods

identify availabe resources

examples of chronic stress and acute stress

chronic:often stems from serious life problems such as poverty, racism, illness, disease, or living in a dysfunctional family system.

Acute:being involved in a motor vehicle accident, experiencing the loss of a loved one, or being a victim of a crime.

what is “GAS:

general adaptive syndrome

body's attempt to maintain equilibrium and homeostasis. Consists of three stages: alarm, resistance, and exhaustion.

alarm: fight or flight epinephrine, norepinephrine, cortisone are released, elevated BP, HR, RR ,menatl alertness

resistance: body functions normalize while responding to stressor stabalizing vitals

exhaustion: body functions no longer able to maintain response to the stressor leading to recovery or death

first stage of sleep

NREM : light sleep, 1-5 mins long, 5% of sleep cycle muscle relaxation, loss of awareness, vitals begin to decrease, awaken easily, drowsy relaxed

second stage of sleep

NREM 2: deeper sleep,

2-25 min long,

vitals & metablolisim continue to slow,

more stimulation to waken,

reduced sympathetic activity 50% of sleep cycle

third stage of sleep cycle

NREM 3: slow wave sleep, or delta sleep

High amplitude electrical brainwaves in the frequency range of 1.0 to 4 hertz.

30-60 mins of mental cloudiness

more difficult to wake

psychological rest and restoration

reduced symphathetic activity

stage 4 of sleep cycle

REM: vivid dreaming

beta waves

90 min after falling alseep reucrring every 90 min

longer with sleep cycle

20 min long

varrying vital signs

difficult to awaken

loss of skeletal tone

cognitive restoration

what is a nurse teachinngs to a pt for promoting sleep routine

• Avoid stimulants, such as caffeine, alcohol, and nicotine, at least 4 to 6 hours before bedtime.

• Remove any unnecessary light and noise; substitute calming white noise if necessary.

• Establish a bedtime routine, such as taking a warm shower or bath before bedtime.

• Keep the room dark, quiet, and at a comfortable, cold temperature.

• Only go to bed when tired. If the client feels restless while attempting to sleep, they should go to another room and do a simple activity like reading or listening to preferred music​​​​​​​.

• Keep a consistent sleep–wake cycle by going to bed and waking at the same time, which allows the body to fall into a biologic rhythm.

• Keep naps short, less than 30 minutes.

• Engage in a regular exercise routine, along with healthy eating; complete exercising at least 3 hours before going to bed.

• Remove all work items and televisions from the bedroom when possible. The bedroom should be associated with sleep and sexual activity only.

When would you not want to massage a pt?

Contraindications to massage include clients with burns, wounds, and on medications to thin their blood (warfarin).

what is theapuetic communication for a terminal ill pt

intiate an open conversation

When giving information about medical conditions how should you give that info to pt’s?

clear, free from slang, medical terminology

what would a client look like with anxiety attack

A client with mild anxiety may exhibit minimal or no physiological manifestations of anxiety, whereas a client with moderate anxiety may appear animated and have slightly elevated vital signs. Clients with severe anxiety will likely exhibit elevated vital signs, diaphoresis, heart palpitations, and muscle tension.

how should you communicate with pts with hearing loss

visual aids

sit and face the client

avoid covering mouth while talking

speak slow and clearly

do not shout

use simple sentences

sign language interpeter if necessary

minimize background noises

what to do if langauge barrier

get medical interpeter

what would you include with therapuetic communication teaching?

open ended questions

give feedback

express empathy

active listening

clarifying the message

giving factual info

when discharing a pt with hearing loss what would you inform them of for health promotion?

do not place objects in ear

have otologist remove any logged items in ear

wear ear protection to high intense noises

blow nose with both nostrils obsutrcted

keeo volume low with headphones

barriers to therapuetic communications

Language differences,

cultural diversities,

speech or hearing impairments,

developmental or cognitive disorders,

medication effects,

effects of recreational drugs,

emotional distress,

environmental factors can all be communication barriers

if pt is a fall risk, how would you assess your pt

When caring for a client who has a mild to moderate vision impairment, the nurse should confirm the client has access to all required corrective lenses, such as prescription eyeglasses or contacts, and reading glasses. Be sure these are in working order and that the client wears them when needed. The nurse should ensure there is adequate lighting in the client’s environment and provide large-print reading materials if necessary. Some clients benefit from the use of a magnifying glass when reading. Face the client when speaking while making eye contact.

For a hospitalized client who has a moderate to severe impairment, or is blind, the nurse should announce their presence and ask permission to enter the client’s room. Instruct the client on the location of items in the room, including the call light. Encourage the client to request assistance with getting out of bed and ambulating. A client may use assistive devices, such as a cane or walking stick, a walker, or a service animal when ambulating. Keep the environment free from clutter to decrease the risk of falls.

what are the 12 cranial nerves, and how would you assess them

“on old olympus towering top a fin van german viewed a mom”

Olfactory I

Sensory to nose for smell

Ask client to identify specific smells, such as coffee or peppermint, testing each nostril separately.

Optic

II Sensory to eye for vision

Test visual acuity using Snellen chart or by having client read printed material.

OculomotorIII

Motor to eye

Check extraocular movements by assessing the 6 directions of gaze.

Check pupillary reaction to light and accommodation.

TrochlearIV

Motor to eye

Assess the 6 directions of gaze.

Trigeminal

V

Sensory to face

Motor to muscles of jaw

Assess corneal reflex.

Palpate the masseter muscles at the temple while client clenches jaw.

Check sensation by lightly touching over the face with a cotton ball.

AbducensVI

Motor to eye

Assess the 6 directions of gaze.

FacialVII

Sensory to tongue for taste

Motor to face for expression

Monitor for symmetry of the face when the client smiles and raises/lowers eyebrows.

Check perception of sweet and salty tastes on the front of the tongue.

Vestibulocochlear (Auditory)VIII

Sensory to ear for hearing and balance

Whisper a word 2 to 3 cm away from one ear while client occludes the other ear. Check both ears.

Observe the client’s balance as they walk.

Glossopharyngeal IX

Sensory to tongue for taste

Motor to pharynx (throat)

Check perception of sweet and sour tastes on the back of the tongue.

Use a tongue blade to check the gag reflex.

Assess the ability to swallow.

Vagus X

Sensory to pharynx

Motor to vocal cords

Parasympathetic innervation to heart lungs, abdominal organs

Have client say “ah” and observe palate and pharynx for movement.

Listen for hoarseness of voice.

Assess pulse, bowel sounds.

Accessory XI

Motor to muscles of neck

Observe ability to turn head side to side.

Monitor client’s ability to shrug shoulders against resistance from examiner’s hands.

HypoglossalXII

Motor to tongue

Ask client to stick tongue out, observe if midline;

Assess ability to move tongue side to side.

how would comminicate w/ pt with impaired speech

allow time for pt to respond

check for comprehension

one person speaks at a time

speak clearly and slowly

tell pt when you do not understand them

picture charts

gestures body language

teaching for diabetic patients related to their feet

such as clients who have diabetic neuropathy. These clients should inspect their feet each day for cuts, blisters, areas of erythema or warmth, and report these to their provider. The client must be cautious when ambulating to avoid injuring the feet or toes.

The nurse should instruct the client to wear closed-toe shoes and avoid walking barefoot. A client who has diabetic neuropathy should follow dietary instructions and take all medications in order to manage blood glucose levels. Doing so can slow the progression of the neuropathy.

how to administer rinnes and webb hearing test

rinnes: A hearing test that is performed with a tuning fork that is vibrated and placed against the mastoid bone and the client is asked to identify when they are unable to hear the sound. The tuning fork is then moved 1 to 2 cm away from the ear and the client indicates if they can still hear the sound.

weber test: turning fork on the middle of head

audiometer: A hearing test whereby a client wears earphones and various sounds at different decibel levels are played in each ear. The client identifies when they can hear each sound

What are the benefits of excersise and what you would emphasize in teaching

excersise everyday 30min to promote sleep but 3 hours before bed

What are the stress disorders

stress-related disorders Stress-related disorders include

acute stress disorder (ASD): An intense and dysfunctional reaction to a traumatic event that lasts less than a month

posttraumatic stress disorder (PTSD):A prolonged and heightened stress reaction to a traumatic event that lasts more than a month.

irritable bowel syndrome (IBS):A gastrointestinal condition characterized by abdominal pain and changes to bowel elimination patterns that can include diarrhea and/or constipation.

what are strategies to enhance communication between nurse and pts

The nurse should ensure that the information is understood by using communication enhancers such as reflecting or summarizing.