Exam #3 Comfort

What is comfort?

A sense of mental, physical, or social well-being.

What is hygiene?

Practices used to preserve health.

What is personal hygiene?

Maintaining individual cleanliness to promote health and comfort.

What are the goals of personal hygiene?

Promote cleanliness, comfort, dignity, infection prevention, and skin integrity.

What should the nurse protect during hygiene care?

Patient privacy, skin integrity, surgical sites, and all tubes, lines, drains, and dressings.

What are the basic principles of bathing?

Maintain privacy, check temperature, use appropriate technique, and change water and wipes as needed.

Why is water or equipment changed during bathing?

To maintain cleanliness and avoid spreading microorganisms.

What is the function of the skin?

It provides a barrier against microorganisms, injury, and fluid loss.

What increases the risk of skin breakdown?

Moisture, friction, shear, immobility, pressure, and poor nutrition.

How can nurses protect skin integrity?

Clean gently, manage moisture, reposition as needed, reduce friction and shear, and support nutrition and hydration.

What is the purpose of perineal care?

Maintain cleanliness, reduce contamination and moisture exposure, and protect skin integrity.

What is the Braden Scale?

A tool used to assess pressure injury risk in adults 18 years and older.

What does a lower Braden score mean?

Greater risk of developing a pressure injury.

What are the six Braden categories?

Sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

What Braden score indicates mild risk in the slides?

15–18.

What Braden score indicates moderate risk?

13–14.

What Braden score indicates high risk?

10–12.

What Braden score indicates very high risk?

9 or lower.

What does Braden sensory perception assess?

The patient's ability to feel and communicate discomfort.

What does Braden moisture assess?

How often the skin is exposed to moisture.

What does Braden activity assess?

The patient's degree of physical activity, especially walking.

What does Braden mobility assess?

The patient's ability to change and control body position.

What does Braden nutrition assess?

The adequacy of food and protein intake.

What does Braden friction and shear assess?

The extent to which skin rubs against surfaces or tissues are distorted by sliding.

What is the difference between activity and mobility?

Activity concerns walking and general physical activity; mobility concerns changing body position.

What is friction?

Rubbing between the skin and another surface.

What is shear?

Distortion of deeper tissues when the skin and underlying tissues move differently.

What is an important intervention for a patient with a low Braden score?

Reposition according to individual needs and facility protocol, while relieving pressure.

Why is nutrition important for skin integrity?

Adequate nutrition and protein support tissue maintenance and wound healing.

What is an important precaution with therapeutic massage?

Avoid massaging reddened bony prominences, suspected pressure injuries, and areas of acute injury.

What is rest?

A decreased state of activity associated with feeling refreshed.

What is sleep?

A temporary state of reduced awareness of the environment and reduced responsiveness.

What interventions help a hospitalized patient whose sleep is disrupted by noise?

Reduce noise and light when safe, cluster care, promote relaxation, and address pain or other sleep barriers.

What interventions may help an older adult who naps late and cannot sleep at night?

Encourage daytime activity, limit long or late naps, and establish a consistent bedtime routine.

What is insomnia?

Difficulty falling asleep, staying asleep, or obtaining restorative sleep.

What is narcolepsy?

A disorder involving excessive daytime sleepiness and episodes of falling asleep.

What is hypersomnia?

Excessive sleepiness or prolonged sleep.

What is restless legs syndrome?

An urge to move the legs with uncomfortable sensations, typically worse at rest and at night.

What is sleep apnea?

Repeated interruptions in breathing during sleep.

What is somnambulism?

Sleepwalking.

What is somniloquy?

Talking during sleep.

What is bruxism?

Grinding or clenching the teeth.

What is nocturnal enuresis?

Urination during sleep.

What are night terrors?

Episodes of intense fear and autonomic arousal during sleep, often with limited recall afterward.

What is a parasomnia?

An unusual behavior or event that occurs during sleep.

What is the difference between dysomnias and parasomnias?

Dysomnias affect sleep amount, timing, or quality; parasomnias involve unusual behaviors or events during sleep.

Why can pain interfere with sleep?

Pain can make it difficult to fall asleep or remain asleep, and poor sleep may increase pain sensitivity.

What are nociceptors?

Sensory nerve endings that detect potentially harmful stimuli and participate in pain signaling.

What is the most reliable indicator of pain in a patient who can self-report?

The patient's own report of pain using an appropriate scale.

What is acute pain?

Pain that often begins rapidly and is associated with injury, surgery, or illness.

What is chronic pain?

Pain that persists or recurs beyond expected healing time or is associated with a chronic condition.

What is cutaneous pain?

Pain originating in the skin or subcutaneous tissue, such as a paper cut.

What is somatic pain?

Pain arising from structures such as muscles, bones, tendons, joints, or connective tissue.

What is visceral pain?

Pain originating in internal organs, often from distention, ischemia, or inflammation.

What is referred pain?

Pain perceived at a location different from its source.

What is an example of referred pain?

Cardiac ischemia may cause discomfort in the arm, shoulder, neck, or jaw.

What is PQRST used for?

A structured assessment of pain characteristics.

What does P in PQRST stand for?

Provocation or palliation: what causes or relieves the pain.

What does Q in PQRST stand for?

Quality: how the pain feels.

What does R in PQRST stand for?

Region or radiation: where the pain is and whether it spreads.

What does S in PQRST stand for?

Severity: the intensity of the pain.

What does T in PQRST stand for?

Timing: when the pain started and its pattern or duration.

What are possible effects of unrelieved pain?

Elevated heart rate, blood pressure or glucose, altered breathing, fatigue, anxiety, depression, poor appetite, and reduced function.

What are Tanner's four clinical judgment steps?

Noticing, interpreting, responding, and reflecting.

What does noticing mean in Tanner's model?

Recognizing relevant patient cues and observations.

What does interpreting mean in Tanner's model?

Making sense of findings and identifying what they may mean.

What does responding mean in Tanner's model?

Taking appropriate nursing action based on the assessment.

What does reflecting mean in Tanner's model?

Evaluating the patient's response and deciding whether care needs to change.

What are common pain assessment scales?

Numeric rating scale, Wong-Baker FACES, FLACC, and selected validated behavioral tools such as CPOT.

What are common routes of analgesic administration?

Oral, topical, rectal, neuraxial, and intravenous; PCA is a method of controlled medication delivery.

What is PCA?

Patient-controlled analgesia, usually delivered through a programmed pump that provides prescribed doses within set limits.

What should nurses monitor during PCA therapy?

Pain relief, sedation, level of consciousness, respiratory rate, oxygen saturation, blood pressure, pulse, and pump settings.

Who ordinarily presses the PCA button?

The patient, when able to understand and operate the pump.

Why is PCA by proxy dangerous?

Another person may give medication when the patient is asleep or sedated, increasing the risk of overdose and respiratory depression.

What does POSS stand for?

Pasero Opioid-Induced Sedation Scale.

What does POSS assess?

The patient's level of sedation associated with opioid therapy.

What are signs of potentially dangerous opioid-induced sedation?

Frequent drowsiness, drifting off during conversation, or minimal response to stimulation.

What should the nurse do if excessive opioid sedation or respiratory depression is suspected?

Withhold further opioid as indicated by protocol, promptly assess airway and breathing, and initiate appropriate escalation or emergency response.

Why must nurses follow PCA policy?

Safe limits, monitoring requirements, and responses depend on the medication, prescription, patient risks, and facility protocols.

What is a nonpharmacologic pain intervention?

A comfort measure such as positioning, relaxation, guided imagery, distraction, or appropriate heat or cold.

What should the nurse do after a pain intervention?

Reassess pain, function, and relevant adverse effects, then document the patient's response.

What information should pain documentation include?

Pain assessment and scale, intervention, medication details when applicable, reassessment, response, and relevant adverse effects.

Where do the slides direct nurses to document pain and sleep in Epic?

Flowsheets, Adult PCS, Body System, Pain/Comfort/Sleep; related vital signs are documented in Vital Signs.

What are the five stages of grief listed in the slides?

Denial, anger, bargaining, depression, and acceptance.

Do all patients experience the stages of grief in order?

No. Grief is individual; stages are not universal or strictly sequential.

What is the priority goal of end-of-life comfort care?

Relieve suffering while respecting dignity, patient wishes, and goals of care.

How can a nurse provide emotional comfort at the end of life?

Listen compassionately, acknowledge feelings, respect cultural and spiritual preferences, and support the patient and family.

Does comfort care mean stopping all care?

No. Care continues with a focus on the patient's goals and relief of suffering.