Unit 2 Review

Acute pain is defined as pain lasting how long, and what is its hallmark?

Less than 3 months; it has an anticipated or predictable end

Chronic pain is defined as pain lasting how long, and what is its hallmark?

Longer than 3 months; it is constant or reoccurring

What is intractable pain?

Pain that is extremely difficult or impossible to manage with standard treatment (example: advanced cancer pain)

What is neuropathic pain?

"Nerve pain" involving the somatosensory system; described as intense, burning, or shooting

Name three examples of neuropathic pain.

Diabetic neuropathy, spinal cord injury, and phantom limb pain

A client describes their pain as burning and shooting. Which type of pain is this most likely?

Neuropathic pain

A client with advanced cancer has pain that does not respond to standard treatment. Which classification is this?

Intractable pain

Which pain scale is used reliably in clients older than 8 years (or children who understand numbers)?

Numeric Rating Scale (NRS), 0-10

Which pain scale uses facial expressions and is appropriate for children ages 3 and older?

Wong-Baker FACES Pain Rating Scale

What does FLACC stand for?

Face, Legs, Activity, Cry, Consolability

FLACC is designed for which clients?

Children aged 2 months to 7 years and clients who are cognitively disabled or cannot self-report pain

How long does the nurse observe a client when using FLACC?

1 to 5 minutes if awake; 5 minutes or longer if asleep

How is each FLACC behavior scored?

0 to 2 for each of the 5 behaviors

What does CRIES stand for?

Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness

CRIES is used for which population?

Infants born at 38 weeks of gestation or later;

useful for postoperative pain in neonates

How is each CRIES category scored?

0 to 2 by the nurse

A CRIES score greater than 4 means what?

Further pain assessment is needed

A CRIES score of 6 or higher means what?

Analgesics should be administered

What does NVPS stand for and which clients is it used for?

Nonverbal Pain Scale; clients unable to verbalize pain (burn units, critical care, sedated, or mechanically ventilated clients)

What five categories does the NVPS assess?

Face, Activity, Guarding, Physiologic I (vital signs), and Respiratory

The NVPS is based on which other pain scale?

FLACC, with adaptations for adult clients

Which pain scale should you use for an unresponsive patient?

NVPS

What behaviors suggest pain in an unresponsive patient?

Groaning, grimacing, crying, restlessness, or refusal of care

What is the best indicator of pain in a client who can communicate?

The client's self-report

What does PQRST stand for?

Precipitating cause, Quality, Region, Severity, Timing

In PQRST, what does "P" assess?

Precipitating cause (what causes or triggers the pain)

In PQRST, what does "Q" assess?

Quality (what the pain feels like)

In PQRST, what does "R" assess?

Region (where the pain is)

In PQRST, what does "S" assess?

Severity (how bad it is, e.g., 0-10)

In PQRST, what does "T" assess?

Timing (onset, duration, frequency)

What is the nurse's responsibility for pain management?

Assess thoroughly, tailor pharmacological and nonpharmacological interventions, treat promptly, reassess after intervention, educate client and family, document everything, and always believe and respect the client's pain report

What factors should the nurse consider when assessing pain?

Culture and development, along with the client's self-report

What vital sign changes are expected with pain?

Elevated heart rate and blood pressure, and increased respiratory rate

What does "guarding" mean?

Voluntary or involuntary tensing of muscles, often when a painful or tender area is palpated

What are the nursing interventions for an unresponsive patient, in order?

1) Verbal stimuli

2) Painful stimuli (pressure to nailbed, sternal rub)

3) Assess breathing and pulse

4) CPR intervention

How does hygiene affect a diabetic client?

High blood sugar slows healing, so even minor cuts or sores can become serious if not cleaned and cared for properly

Who usually takes care of nail care for diabetic clients?

A podiatrist

Why might an older adult resist showering or bathing?

• Illness,

• disease,

• pain,

• fear of falling,

• fear of water temperature,

• difficulty getting in/out of the shower,

• lack of energy

What should the nurse do when a geriatric client resists bathing?

Determine the reason and work with the client to find a solution; give the client choices

How does hygiene protect the skin integrity of older adults?

Avoid rubbing; assess for bruising, skin tears, pressure injuries, and maceration; clean and dry skin promptly after incontinence; prevent falls; encourage the client to do as much care as possible

What hygiene approach is used for a client with dementia?

Use simple 1-step instructions and nontraditional methods of bathing; they may have poorer hygiene due to cognitive decline

Why do adolescents need extra hygiene education?

Puberty causes hormonal changes, increased sweating, and more oily skin (forehead, nose, chin);

they need education, reminders, and encouragement to establish consistent habits

What hygiene guidance is given to adolescents?

Bathe daily, wash hair at least every other day, use deodorant daily, and use noncomedogenic soaps/cleansers

Why should adolescents use noncomedogenic cleansers?

To prevent oily skin and clogged pores

How often should infants be bathed?

No more than 3 times per week to prevent skin drying

What type of bath is given to an infant until the umbilical cord falls off?

Sponge bath (cord falls off 1-2 weeks after birth)

How do you care for the umbilical cord?

Keep the cord and stump clean and dry until it falls off

What infant diaper care is recommended?

Change diapers frequently, wash with water and soap-free cleansers, and use topical emollients as a barrier between skin and diaper

List the overall benefits of good hygiene.

Prevents infection and HAIs, protects skin, supports oral and systemic health, improves comfort and function, promotes emotional well-being and independence, provides opportunity for assessment, reduces complications

Name examples of anticoagulants.

Heparin, enoxaparin, warfarin, apixaban, and even aspirin

What hygiene precautions apply to a patient on anticoagulants?

Gentle skin care;

avoid vigorous rubbing or forceful nail care;

use light short strokes instead of firm massage if at risk for DVT;

use electric shavers; fall prevention;

skin assessment;

report abnormal bleeding or bruising promptly

Why should an anticoagulated patient use an electric shaver?

Bleeding prevention

When dressing a stroke patient, which arm is used first?

The unaffected arm places clothing on the affected side first

When undressing a stroke patient, which side is removed first?

The unaffected side

What is a panus?

A skin fold in the abdomen that folds over the groin (seen in bariatric clients)

What hygiene problems are common in bariatric clients?

• Higher need for assistance with ADLs,

• deep skin folds,

• sweating and persistent moisture leading to fungal infections,

• irritant dermatitis from inability to clean after toileting

What medication may be discussed with the provider for fungal infection in skin folds?

Nystatin powder

How can medications affect hygiene?

They can cause fatigue, dizziness, or motor impairment, or increase sensitivity to odors and skin irritation; nurses should assess effects and provide support or adaptations

What are the ways to perform oral care?

Brushing, flossing, mouthwash, and denture care

How often and how long should teeth be brushed?

2 times a day for 2 minutes each time

How often should you floss?

Once a day (after meals when appropriate or after vomiting)

What is the focus of oral care for an unresponsive client?

Preventing aspiration, infection, and mouth injury

How do you position an unresponsive client for oral care?

Head elevated, side-lying, or head tilted to the side, with suction available

What oral care is used for clients with artificial airways?

Mouth rinses, gels, toothbrushing, and suctioning of secretions

Why is oral care imperative?

Prevents cavities, plaque, gingivitis, and periodontal disease; prevents dry cracked mouth/lips; reduces bacteria that can enter the bloodstream or lungs; prevents ventilator-associated pneumonia (an HAI)

What HAI is prevented by good oral care in ventilated patients?

Ventilator-associated pneumonia (VAP)

List the steps of oral care.

1) Hand hygiene and gloves 2) Explain and provide privacy 3) Position upright (side-lying with suction if unresponsive) 4) Remove dentures/appliances 5) Brush teeth, gums, tongue, cheeks, palate gently 6) Rinse/wipe mouth, suction if needed 7) Apply lip moisturizer 8) Clean and store dentures safely 9) Assess for sores, bleeding, loose teeth, thrush, dryness, foul odor 10) Remove gloves, hand hygiene, document abnormal findings

What should you assess for during oral care?

Sores, bleeding, loose teeth, thrush, dryness, or foul odor

What is the normal adult heart rate?

60-100 bpm

What is tachycardia?

Heart rate greater than 100 bpm in an adult

What is bradycardia?

Heart rate below 60 bpm in an adult

What are possible causes of tachycardia?

• Exercise,

• anxiety,

• caffeine,

• nicotine,

• medications,

• dehydration,

• hyperthyroidism,

• fever,

• abnormal cardiac electrical activity

How do you treat stable tachycardia?

Valsalva (vagal) maneuver and stop or reduce contributing stimulants

Which signs make tachycardia unstable?

Chest pain, shortness of breath, altered mental status, fainting, or low BP;

requires immediate emergency response

What are possible causes of bradycardia?

Congenital cardiac abnormalities, heart failure, heart muscle damage, hypothyroidism, or medications;

may be normal in well-conditioned athletes

How do you manage stable/asymptomatic bradycardia?

Recheck pulse for a full minute and assess rhythm;

notify provider if new, worsening, or significantly below baseline

What signs make bradycardia unstable?

• Dizziness

• fatigue

• shortness of breath

• chest pain

• confusion

• fainting

• decreased level of consciousness

How do you manage unstable bradycardia?

Activate emergency response, notify provider, and prepare for atropine as prescribed

Which medication is prepared for symptomatic bradycardia?

Atropine

What is the expected adult temperature range?

96.8-100.4 F (36-38 C)

What temperature is hypothermia?

Below 96.8 F

What temperature is considered elevated/fever?

Above 100.4 F

What is the expected adult respiratory rate?

12-20 breaths/min

What is bradypnea?

Respirations below 12/min

What is tachypnea?

Respirations above 20/min

What is apnea?

Absent respirations

What is the expected adult blood pressure?

Usually about less than 120/80 mmHg

What blood pressure defines hypotension?

Below 90/60

What is stage 1 hypertension?

BP 130-139 systolic or 80-89 diastolic

What is stage 2 hypertension?

BP 140/90 or higher

What blood pressure is a hypertensive crisis?

180/120 mmHg or higher, especially if symptoms are present

A patient's BP is 135/76. Which stage is this?

Stage 1 hypertension;

systolic and diastolic numbers are evaluated separately, and the systolic (135) falls in stage 1

What is the expected oxygen saturation?

95-100%

What oxygen saturation is hypoxia requiring prompt assessment?

Below 90%

What phrase reminds you to look at the patient, not just numbers?

"Treat the patient, not the monitor."

What should you do if an electronic blood pressure reading is unexpected?

Recheck it manually

What should you compare vitals to?

The patient's usual baseline and trends, not only a single number

In addition to the monitor, what should you assess in the patient?

Symptoms, breathing, skin color, mental status, and overall condition

What blood pressure is considered unstable?

Systolic less than 90 or greater than 180 mmHg (with symptoms);

diastolic less than 60; or BP trending rapidly downward

What pulse is considered unstable?

Less than 60 or more than 100/min with symptoms, or persistently outside normal range