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Nursing School > 💉- Ethics, Pain & Pressure Ulcer Test > Flashcards

💉- Ethics, Pain & Pressure Ulcer Test Flashcards

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0
Q

Moral outrage

A

Belief that others are acting immorally

Powerlessness:

  • can’t prevent a “wrong”
  • respond with “whistleblowing”
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1
Q

What is moral distress

A

Inability to carry out a moral decision

Perceived constraints:
Physicians 
Administrators
Other nurses
Law/threat of lawsuit
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2
Q

List 5 factors that affect moral decisions

A 
Developmental stage 
Values 
Ethical framework 
Ethical principals 
Professional guidelines
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3
Q

List 3 things that affect ethical decisions

A

Values , attitudes , beliefs

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4
Q

What is moral or ethical agency

A

For nurses is the ability to base their practice on professional standards of ethical conduct and to participate in ethical decision making

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5
Q

Values

A

Belief about the worth of something

Freely chosen; often learned

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6
Q

Attitudes

A

Feelings toward person, object, idea

What a person thinks

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7
Q

Beliefs

A

Something that one accepts as true

Not always bases on fact

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8
Q

Name the 5 principles of ethics

A 
Nonmaleficence
Beneficence 
Fidelity 
Veracity 
Justice
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9
Q

Nonmaleficence

A

Do no harm

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10
Q

Beneficence

A

Duty to do good

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11
Q

Fidelity

A

Loyalty

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12
Q

Veracity

A

Tell the truth

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13
Q

Justice

A

Be fair

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14
Q

List the 5 professional nursing values

A 
Altruism 
Autonomy
Human dignity 
Integrity 
Social justice
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15
Q

Altruism

A

Being concerned about well being of others

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16
Q

Autonomy

A

Right to choose what they do/informed consent

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17
Q

Human dignity

A

Having respect for people

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18
Q

Integrity

A

Nursing code of ethics

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19
Q

Social justice

A

Treating everybody fairly

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20
Q

What does it mean to be an advocate

A

You work to protect and support another persons rights

  • commitment is always to patient not co worker or institution
  • promoting the patients dignity
  • evaluating the patients autonomy
  • acting as the patients voice when they can’t
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21
Q

What does HIPAA stand for

A

The health insurance portability and accountability act

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22
Q

EMTALA

A

Emergency medical treatment and active labor act

Requires healthcare facilities to provide emergency medical treatment to patients regardless of ability to pay and citizenship status

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23
Q

PSDA

A

Patient self determination act

Recognizes the patients right to make decisions regarding his own healthcare

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24
Q

ADA

A

Americans with disabilities act

Provides protection against discrimination of individuals with disabilities

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25
Q

What do nurse practice acts do

A

Statutory laws passed by EACH STATE’s legislative body that define the practice of nursing ; scope of practice

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26
Q

Where can the nursing practice acts he located

A

On the state board of nursing website

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27
Q

American nurses association code of ethics

A

Describes the standards of professional responsibility for nurses and provides insight into ethical and acceptable behavior

Is not a law

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28
Q

The ANA guarantees the patient the right to

A

Dignity, privacy and safety

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29
Q

What is criminal law

A

Wrongs or offenses against society

Ex: felonies and misdemeanors

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30
Q

What is civil law

A

Disputes between individuals

Ex: contact law and tort law

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31
Q

What are tort laws

A

Wrongs done to one person by another person that do not involve contracts

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32
Q

What are Quasi-intentional torts ? And give 2 examples

A

Involve actions that injure a persons reputation

Ex: libel or slander

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33
Q

Libel

A

Is the written or published form of defamation of character

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34
Q

Slander

A

Is the spoken or verbal form of defamation of character

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35
Q

What are Intentional torts ? And list 4 examples

A

An action taken by one person with the intent to harm another person

Ex:assault/battery, false imprisonment, invasion of privacy and fraud

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36
Q

Fraud

A

Is the false representation of significant facts by words or by conduct

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37
Q

What are unintentional torts ? And give 2 examples

A

Negligence and malpractice

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38
Q

Malpractice

A

Failure to act as a ‘reasonable and prudent’ nurse / failure to do what a reasonable and prudent nurse would do in the same situation

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39
Q

Plaintiff

A

The person bringing the lawsuit

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40
Q

Defendant

A

The person who must defend against the lawsuit

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41
Q

To win and recover damages (money) in a malpractice lawsuit , the plaintiff must prove what 4 things

A

Duty
Breach of duty
Causation
Damages

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42
Q

Where would find national patient safety goals

A

On the joint commission website

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43
Q

List 5 safety risks in the healthcare facility

A
  • falls
  • equipment failure/accidents
  • fire
  • restraints
  • never events
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44
Q

What are NEVER events

A

Can cause serious injury or death to a patient and should never happen in a hospital

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45
Q

List 8 examples of NEVER events

A 
1 foreign objects 
2 air embolism 
3 wrong blood 
4 pressure ulcers 
5 infections from urinary or IV catheters
6 uncontrolled blood sugar 
7 surgical site infections 
8 vte (deep vein thrombosis)
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46
Q

What does the acronym RACE stand for

A

R- rescue
A- activate
C- confine
E- extinguish

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47
Q

What does the acronym PASS stand for

A

P- pull
A- aim
S- squeeze
S- sweep

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48
Q

What is a restraint

A

Anything that restricts a patients freedom to move

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49
Q

List 5 hazards to healthcare workers

A 
1 biological hazards (infectious diseases/biological weapons)
2 back/neck/body injuries 
3 needle stick injuries 
4 radiation exposure 
5 violence
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50
Q

What are the 3 domains of learning

A

Cognitive , psychomotor , affective learning

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51
Q

What is cognitive learning

A

Is storing and recalling information in the brain

Ex: asking a question over something you just said / lecture and test questions

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52
Q

What is psychomotor learning

A

Is learning a skill that requires both mental and physical activity

Ex: demonstrating how to perform an action, like an insulin injection / skill lab and check offs

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53
Q

What is affective learning

A

Is changes in feelings, beliefs, attitudes and values

Ex: how do you feel about a diagnosis? What are your fears / clinical experiences and reflective journaling

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54
Q

How can you determine that learning occurred

A

You must document your teaching and the clients verbalized response

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55
Q

Body mechanics

A

Is the way we move our bodies

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56
Q

What are the 4 components of body mechanics

A

Body alignment (posture)
Balance
Coordination
Joint mobility (bend, sit, move, etc)

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57
Q

What is isometric exercise

A

Muscle contraction without motion

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58
Q

What is isotonic exercise

A

Movement of joint with muscle contraction (free weights)

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59
Q

What is isokinetic exercise

A

Using equipment to provide resistance against movement (weight machines)

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60
Q

Aerobic exercise

A

The amount of oxygen taken in during activity meets the bodies needs (walking, jogging, bicycling)

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61
Q

Anaerobic exercise

A

Amount of oxygen taken in during activity doesn’t meet the bodies needs (lifiting, sprinting)

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62
Q

List 4 nursing measures to promote activity and exercise

A
  • promote exercise
  • positioning patients
  • helping the client out of bed
  • assisting with ambulation
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63
Q

What is a trochanter roll

A

Goes from top of the hip to knee; to prevent external hip rotation

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64
Q

What is orthopneic position

A

Sitting at a 90degree angle with tray over bed and elbows laying on top in a triangle

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65
Q

What is fowlers position

A

Is a semi sitting position, in which the head of the bed is elevated 45-60 degrees

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66
Q

Semi-fowlers position

A

Head of the bed is elevated only 30 degrees

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67
Q

High fowlers position

A

Head of the bed is elevated to 90degrees

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68
Q

What is lateral position

A

Side-lying position with the top hip and knee flexed and placed in front of the rest of the body

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69
Q

Prone position

A

That patient lies on his abdomen with his head turned to one side

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70
Q

Sims position

A

Is a semi prone position

Used to give enemas

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71
Q

Supine position

A

Patients lies on his back with head and shoulders elevated on a small pillow

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72
Q

What are conditioning exercises

A

Things that you have the patient do to make sure they can stand before ambulation

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73
Q

Health

A

Could be considered as the highest level of physical, emotional and social functioning possible for any given individual

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73
Q

Health

A

Could be considered as the highest level of physical, emotional and social functioning possible for any given individual

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74
Q

Illness

A

Could be considered anything that prevents an individual from achieving their highest possible level of health

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74
Q

Illness

A

Could be considered anything that prevents an individual from achieving their highest possible level of health

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75
Q

Meaningful work

A

Is doing something that you enjoy

That contributes to health

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75
Q

Meaningful work

A

Is doing something that you enjoy

That contributes to health

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76
Q

Competing demands

A

Is when life still goes on even though you’re sick

A factor that disrupts health

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76
Q

Competing demands

A

Is when life still goes on even though you’re sick

A factor that disrupts health

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77
Q

Acute

Nature of illness

A

Sudden onset and lasts short time

Ex: cold

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77
Q

Acute

Nature of illness

A

Sudden onset and lasts short time

Ex: cold

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78
Q

Chronic

Nature of Illness

A

6 months or greater

Ex: diabetes , AIDS

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78
Q

Chronic

Nature of Illness

A

6 months or greater

Ex: diabetes , AIDS

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79
Q

Remission

A

Symptoms are minimal to none

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79
Q

Remission

A

Symptoms are minimal to none

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80
Q

Exacerbation

A

Symptoms ‘flare-up’

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80
Q

Exacerbation

A

Symptoms ‘flare-up’

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81
Q

Hardiness

A

Ones ability to survive, will to live, adapting to change

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81
Q

Hardiness

A

Ones ability to survive, will to live, adapting to change

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82
Q

Burn-out

A

Too many demands over too long a period

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82
Q

Burn-out

A

Too many demands over too long a period

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83
Q

What is psychosocial health

A

Includes our mental health, emotions and how we interact with those around us

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83
Q

What is psychosocial health

A

Includes our mental health, emotions and how we interact with those around us

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84
Q

Self-concept

A

Who YOU think you are

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84
Q

Self-concept

A

Who YOU think you are

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85
Q

Development level

A

Is the part of self-concept where the older you get the less you’re concerned about what others think

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85
Q

Development level

A

Is the part of self-concept where the older you get the less you’re concerned about what others think

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86
Q

Role performance

A

Is a component of self concept ; things that we do (behavior and actions) to fulfill a certain role

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86
Q

Role performance

A

Is a component of self concept ; things that we do (behavior and actions) to fulfill a certain role

87
Q

True or false: low levels of anxiety are necessary

A

True

87
Q

True or false: low levels of anxiety are necessary

A

True

88
Q

Depressed mood is typically marked by

A

A sense of emptiness

88
Q

Depressed mood is typically marked by

A

A sense of emptiness

89
Q

List 6 signs of depression

A
  • depressed mood most of the day nearly everyday for at least 2 weeks/diminished interest or pleasure in activities the person previously enjoyed
  • insomnia or hypersomnia
  • loss of energy
  • feelings of worthlessness
  • diminished ability to concentrate
  • recurrent thoughts of death
89
Q

List 6 signs of depression

A
  • depressed mood most of the day nearly everyday for at least 2 weeks/diminished interest or pleasure in activities the person previously enjoyed
  • insomnia or hypersomnia
  • loss of energy
  • feelings of worthlessness
  • diminished ability to concentrate
  • recurrent thoughts of death
90
Q

What is depersonalization

A

The feeling that people are doing things ‘to’ you instead of ‘with’ you

Lack of control over what’s being done to them

90
Q

What is depersonalization

A

The feeling that people are doing things ‘to’ you instead of ‘with’ you

Lack of control over what’s being done to them

91
Q

List 9 warning signs of suicide

A 
1 withdrawal 
2 desire to be left alone 
3 risk-taking behavior 
4 changes in routine 
5 changes in eating 
6 giving away belongings 
7 personality changes 
8 saying goodbye 
9 talking about suicide
91
Q

List 9 warning signs of suicide

A 
1 withdrawal 
2 desire to be left alone 
3 risk-taking behavior 
4 changes in routine 
5 changes in eating 
6 giving away belongings 
7 personality changes 
8 saying goodbye 
9 talking about suicide
92
Q

Affect

A

Feelings

92
Q

Affect

A

Feelings

93
Q

Anhedonia

A

A loss of interest or pleasure in previously enjoyable activities

93
Q

Anhedonia

A

A loss of interest or pleasure in previously enjoyable activities

94
Q

What are the 4 health and illness roles of the nurse

A

Promote health

Prevent illness

Restore health

Facilitate coping

94
Q

What are the 4 health and illness roles of the nurse

A

Promote health

Prevent illness

Restore health

Facilitate coping

95
Q

What is health promotion

A

“A desire to increase your well being”

Finding ways to help ourselves, or our patients, heal or maintain a state of physical, spiritual and mental well-being

95
Q

What is health promotion

A

“A desire to increase your well being”

Finding ways to help ourselves, or our patients, heal or maintain a state of physical, spiritual and mental well-being

96
Q

What is Primary prevention ? And give examples

A

Activities are designed to prevent or slow the onset of disease

Ex: diet, exercise, wearing sunscreen etc

96
Q

What is Primary prevention ? And give examples

A

Activities are designed to prevent or slow the onset of disease

Ex: diet, exercise, wearing sunscreen etc

97
Q

What is secondary prevention ? And give examples

A

Involves screening activities and education for detecting illnesses in the early stages

Ex: screenings (breast, testicular exams) BP and diabetes screening, tb skin test

Education
Family counseling

97
Q

What is secondary prevention ? And give examples

A

Involves screening activities and education for detecting illnesses in the early stages

Ex: screenings (breast, testicular exams) BP and diabetes screening, tb skin test

Education
Family counseling

98
Q

What is Tertiary prevention ? Give examples

A

Focuses on stopping the disease from processing and returning the individual to the pre-illness phase

Ex: medications: Lipitor (treats high cholesterol) , surgical/rehab/PT

98
Q

What is Tertiary prevention ? Give examples

A

Focuses on stopping the disease from processing and returning the individual to the pre-illness phase

Ex: medications: Lipitor (treats high cholesterol) , surgical/rehab/PT

99
Q

Stratum corneum

A

The outermost layer of skin

99
Q

Stratum corneum

A

The outermost layer of skin

100
Q

Stratum germinativum

A

The innermost layer is the epidermis, continually produces new cells pushing the older cells towards the skin surface

100
Q

Stratum germinativum

A

The innermost layer is the epidermis, continually produces new cells pushing the older cells towards the skin surface

101
Q

Partial thickness

A

Loss of epidermis
Caused by trauma
Not caused by ischemia

101
Q

Partial thickness

A

Loss of epidermis
Caused by trauma
Not caused by ischemia

102
Q

Full thickness

A
  • total loss of epidermis and dermis

- may extend to subcutaneous, fascia, muscle, bone

102
Q

Full thickness

A
  • total loss of epidermis and dermis

- may extend to subcutaneous, fascia, muscle, bone

103
Q

Clean wounds

A

Uninflected wounds with minimal inflammation

Don’t involve gi, gu or respiratory tract

103
Q

Clean wounds

A

Uninflected wounds with minimal inflammation

Don’t involve gi, gu or respiratory tract

104
Q

Clean-contaminated wounds

A

Surgical incisions involving gi, gu or respiratory tract

104
Q

Clean-contaminated wounds

A

Surgical incisions involving gi, gu or respiratory tract

105
Q

Contaminated wounds

A

Include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred

105
Q

Contaminated wounds

A

Include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred

106
Q

Infected wounds

A

Bacteria present and causing damage

106
Q

Infected wounds

A

Bacteria present and causing damage

107
Q

Primary intention healing

A

When a wound involves minimal or no tissue loss and has edges that are well approximated

107
Q

Primary intention healing

A

When a wound involves minimal or no tissue loss and has edges that are well approximated

108
Q

Secondary intention healing

A

Occurs when a wound involves extensive tissue loss, which prevents wound edges from approximating or should not be closed

Left open to heal

108
Q

Secondary intention healing

A

Occurs when a wound involves extensive tissue loss, which prevents wound edges from approximating or should not be closed

Left open to heal

109
Q

Tertiary intention healing

A

Initially healed through secondary intention

Later closed to approximate edges

109
Q

Tertiary intention healing

A

Initially healed through secondary intention

Later closed to approximate edges

110
Q

Stage I of the healing process

A

Inflammatory Phase (cleansing)

Last from 1 to 5 days and consists of: hemostasis and inflammation

110
Q

Stage I of the healing process

A

Inflammatory Phase (cleansing)

Last from 1 to 5 days and consists of: hemostasis and inflammation

111
Q

Stage II of the healing process

A

Proliferation Phase (granulation)

Occurs from days 5 to 21. Healthy cells work to replace lost tissue

Granulation tissue is formed, but is very friable

111
Q

Stage II of the healing process

A

Proliferation Phase (granulation)

Occurs from days 5 to 21. Healthy cells work to replace lost tissue

Granulation tissue is formed, but is very friable

112
Q

Friable

A

Easily crumbled

112
Q

Friable

A

Easily crumbled

113
Q

Stage III of the healing process

A

Maturation Phase (epithelialization)

Granulation tissue becomes scar tissue

Scar tissue is stronger than granulation, but never as strong as the original tissue

113
Q

Stage III of the healing process

A

Maturation Phase (epithelialization)

Granulation tissue becomes scar tissue

Scar tissue is stronger than granulation, but never as strong as the original tissue

114
Q

Serous exudate

A

Straw colored (yellow) clear and watery drainage from clean wounds

114
Q

Serous exudate

A

Straw colored (yellow) clear and watery drainage from clean wounds

115
Q

Sanguineous exudate

A

Bloody drainage , that indicates damage to capillaries

From full thickness wounds

115
Q

Sanguineous exudate

A

Bloody drainage , that indicates damage to capillaries

From full thickness wounds

116
Q

Serosanguineous exudate

A

Combination of serous and sanguineous

Typically from fresh wounds

116
Q

Serosanguineous exudate

A

Combination of serous and sanguineous

Typically from fresh wounds

117
Q

Purulent exudate

A

Thick, foul odor, pus; yellow or blue/green

WBC’s ,bacteria, debris

117
Q

Purulent exudate

A

Thick, foul odor, pus; yellow or blue/green

WBC’s ,bacteria, debris

118
Q

What could the presence of blue-green purulent exudate mean

A

Pseudomonas aeruginosa is present

118
Q

What could the presence of blue-green purulent exudate mean

A

Pseudomonas aeruginosa is present

119
Q

Purosanguienous exudate

A

Combination of sanguineous and purulent

Infected wound that is causing vascular damage

119
Q

Purosanguienous exudate

A

Combination of sanguineous and purulent

Infected wound that is causing vascular damage

120
Q

Hematoma

A

Red-blue collection of blood under the skin, which forms as a result of bleeding that can’t escape to the surface

120
Q

Hematoma

A

Red-blue collection of blood under the skin, which forms as a result of bleeding that can’t escape to the surface

121
Q

Dehiscence

A

Separation of wound layers

121
Q

Dehiscence

A

Separation of wound layers

122
Q

Evisceration

A

Total separation of the layers of a wound with internal viscera protruding through the incision

122
Q

Evisceration

A

Total separation of the layers of a wound with internal viscera protruding through the incision

123
Q

Fistula

A

An abnormal passage connecting two body cavities or a cavity and the skin

123
Q

Fistula

A

An abnormal passage connecting two body cavities or a cavity and the skin

124
Q

How long can it take a pressure ulcer to form

A

Can occur after only 2 hours

124
Q

How long can it take a pressure ulcer to form

A

Can occur after only 2 hours

125
Q

Friction

A

Damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions

125
Q

Friction

A

Damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions

126
Q

Shearing

A

Occurs when the epidermal layer sliders over the dermis, causing damage to the vascular bed

126
Q

Shearing

A

Occurs when the epidermal layer sliders over the dermis, causing damage to the vascular bed

127
Q

List 4 Intrinsic factors creating a risk for pressure ulcers

A

Internal factors that alter skin and tissue integrity or oxygen delivery capabilities

Immobility
Impaired sensation
Poor nutrition
Dehydration

127
Q

List 4 Intrinsic factors creating a risk for pressure ulcers

A

Internal factors that alter skin and tissue integrity or oxygen delivery capabilities

Immobility
Impaired sensation
Poor nutrition
Dehydration

128
Q

List 4 extrinsic factors that can create a risk for pressure ulcers

A

External factors that contribute to the development of pressure ulcers

Friction
Shearing
Exposure to moisture
Compression

128
Q

List 4 extrinsic factors that can create a risk for pressure ulcers

A

External factors that contribute to the development of pressure ulcers

Friction
Shearing
Exposure to moisture
Compression

129
Q

Pressure Ulcer Stage I

A

Intact skin, non blanchable redness

129
Q

Pressure Ulcer Stage I

A

Intact skin, non blanchable redness

130
Q

Pressure ULCER stage II

A

Partial thickness; affecting the epidermis or partial dermis

No slough or Eschar present

130
Q

Pressure ULCER stage II

A

Partial thickness; affecting the epidermis or partial dermis

No slough or Eschar present

131
Q

Pressure ulcer stage III

A

Full thickness; subcutaneous fat is visible , but no muscle tendon or bone

Slough or eschar may be present

131
Q

Pressure ulcer stage III

A

Full thickness; subcutaneous fat is visible , but no muscle tendon or bone

Slough or eschar may be present

132
Q

Pressure ulcer stage IV

A

Full thickness; muscle tendon and/or bone exposed

132
Q

Pressure ulcer stage IV

A

Full thickness; muscle tendon and/or bone exposed

133
Q

Suspected deep tissue injury

A

Intact skin that appears purple or maroon; blood filled blister

133
Q

Suspected deep tissue injury

A

Intact skin that appears purple or maroon; blood filled blister

134
Q

Unstageable

A

Base of wound is covered with slough or eschar

134
Q

Unstageable

A

Base of wound is covered with slough or eschar

135
Q

Venous stasis ulcers

A

Irregularly shaped lesions caused by venous congestion, often from damage to valves in the veins

Occurs usually between the inside ankle and the knee ; not necessarily over a bony prominence

135
Q

Venous stasis ulcers

A

Irregularly shaped lesions caused by venous congestion, often from damage to valves in the veins

Occurs usually between the inside ankle and the knee ; not necessarily over a bony prominence

136
Q

Diabetic foot ulcers

A

Occur when diabetes causes the narrowing of arteries, decreasing oxygenation to the feet that result in delayed healing and tissue necrosis

136
Q

Diabetic foot ulcers

A

Occur when diabetes causes the narrowing of arteries, decreasing oxygenation to the feet that result in delayed healing and tissue necrosis

137
Q

Arterial ulcers

A

Occur when there is a non-pressure-related blockage of arterial blood to an area causing ischemia and tissue necrosis

Usually occurs over the lower leg, ankle robbing areas of the foot

137
Q

Arterial ulcers

A

Occur when there is a non-pressure-related blockage of arterial blood to an area causing ischemia and tissue necrosis

Usually occurs over the lower leg, ankle robbing areas of the foot

138
Q

The Braden scale

A

Is used to identify persons at risk for developing pressure ulcers

138
Q

The Braden scale

A

Is used to identify persons at risk for developing pressure ulcers

139
Q

Periwound

A

Is the skin surrounding the wound

139
Q

Periwound

A

Is the skin surrounding the wound

140
Q

Maceration

A

Is caused by excessive moisture for periods of time

140
Q

Maceration

A

Is caused by excessive moisture for periods of time

141
Q

Epiboly

A

Closed or rolled wound edges

141
Q

Epiboly

A

Closed or rolled wound edges

142
Q

Debridement

A

Is the removal of devitalized tissue or foreign material from a wound

142
Q

Debridement

A

Is the removal of devitalized tissue or foreign material from a wound

143
Q

Senescent

A

Cells that are alive but not functioning

That can be removed by debridement

143
Q

Senescent

A

Cells that are alive but not functioning

That can be removed by debridement

144
Q

List 9 points to include in client teaching about wound care

A

1 characteristics of healthy skin
2 appearance of skin that has experienced unrelieved pressure
3 skin care and hygiene
4 protection of the skin and prevention of pressure ulcers
5 importance of adequate nutrition
6 techniques for turning and positioning
7 importance of frequent position changes
8 use of pressure-redistributing devices
9 skin changes that should be reported to healthcare professionals

144
Q

List 9 points to include in client teaching about wound care

A

1 characteristics of healthy skin
2 appearance of skin that has experienced unrelieved pressure
3 skin care and hygiene
4 protection of the skin and prevention of pressure ulcers
5 importance of adequate nutrition
6 techniques for turning and positioning
7 importance of frequent position changes
8 use of pressure-redistributing devices
9 skin changes that should be reported to healthcare professionals

145
Q

The acronym WOUND stands for what as a teaching tool for wound care

A 
Wet --> dry it 
Open --> cover it 
Unclean --> clean it 
Necrotic --> don't scrub it 
Dry --> moisten it
145
Q

The acronym WOUND stands for what as a teaching tool for wound care

A 
Wet --> dry it 
Open --> cover it 
Unclean --> clean it 
Necrotic --> don't scrub it 
Dry --> moisten it
146
Q

Sensory deprivation

A

Is a state of RAS depression caused by a lack of meaningful stimuli

147
Q

RAS

A

Reticular activating system - located in the brain stem, controls consciousness and alertness

148
Q

Sensory overload

A

Develops when either environmental or internal stimuli - or a combination of both - exceed a higher level than the patients sensory system can effectively process

149
Q

List 4 nursing interventions for sensory deprivation

A
  • focus on prevention
  • support senses (glasses, hearing aids)
  • orientation (calendar, view of environment)
  • provide stimuli (regular contact, touch, tv, radio etc)
150
Q

Nursing interventions for sensory overload

A

Minimize stimuli

Less light , noise 
Less tv, radio
Calm tone 
Reduce noxious odors 
Provide rest
Teach stress reduction
151
Q

What is pain

A

Whatever the patient says it is, existing whenever the patient says it does

152
Q

It’s the 6 origins of pain

A

The site where pain is felt; and not necessarily the source of pain

Superficial 
Visceral 
Somatic 
Radiating/referred 
Phantom 
Psychogenic
153
Q

Superficial pain

A

Arises in the skin or the subcutaneous tissue

Ex: touching a hot object or getting a paper cut

154
Q

Visceral pain

A

Caused by the stimulation of deep internal pain receptors

Most often in the stomach, brain or thorax - described as tight, pressure, or crampy pain

155
Q

Deep somatic pain

A

Originates in the ligaments tendons, nerves, blood vessels and bones

Ex: fracture or sprain, arthritis and bone cancer can cause deep somatic pain - described as achy or tender

156
Q

Radiating pain

A

Starts at the origin but extends to other locations

157
Q

Referred pain

A

Occurs in an area that is distant from the original site

Ex: the pain from a heart attack may be experienced down the left arm

158
Q

Phantom pain

A

Is pain that is perceived to originate from an area that has been surgically removed

159
Q

Psychogenic pain

A

Refers to pain that is believed to arise from the mind

Ex: the patient perceives the pain despite the fact that no physical cause can be identified

233
Q

Acute pain

A
  • short duration rapid in onset
  • varies in intensity
  • lasts up to 6 months
234
Q

Chronic pain

A
  • last 6 months or longer
  • interferes with daily activities
  • can be related to a progressive disorder
235
Q

Intractable pain

A
  • both chronic and highly resistant to relief

- should be approached with multiple methods of pain relief

236
Q

Transduction

A

Activation of nociceptors by stimuli

-mechanical, thermal, chemical

237
Q

Nociceptive pain

A

Occurs when pain receptors, called nociceptors respond to stimuli that are potentially damaging

May occur as a result of trauma, surgery or inflammation - it is mostly commonly described as aching

Ex: visceral and somatic

238
Q

Neuropathic pain

A

Chronic pain that arises when injury to one or more nerves results in repeated transmission of pain signals even in the absence of painful stimuli

Described as burning, numbness, itching and “pins and needles” prickling pain

239
Q

Mechanical stimuli

A

External forces that result in pressure or friction against the body

Ex: surgical incisions, friction or skin shearing from sliding down in bed, etc

240
Q

Thermal stimuli

A

Result from exposure to extreme heat or cold

241
Q

Chemical stimuli

A

Can be internal or external

Ex: lemon juice in a cut or chest pain experienced during a heart attack

242
Q

Transmission

A

Conduction of pain message to spinal cord

243
Q

A-delta fibers

A

Myelinated fibers that Transmit fast pain impulses from acute, focused mechanical and thermal stimuli

244
Q

C fibers

A

Unmyelinated fibers that transmit slow pain impulses from mechanical, thermal or chemical stimuli

Ex: bump your knee, the lingering ache in the tissue will be carried by C fibers

245
Q

Substance P

A

Neurotransmitter which carries pain impulses across the synapses

  • some pain messages enter the reticular formation of the brain stem
  • others are transmitted to the thalamus where they are directed to 3 regions of the brain (somatosensory, limbic system, frontal)
246
Q

Somatosensory

A

Physical sensations

247
Q

Limbic system

A

Emotional reactions to stimuli

248
Q

Frontal cortex

A

Thought and reason

249
Q

List 3 nonverbal signs of pain

A

Elevated pulse/blood pressure

Crying, moaning

Grimacing

250
Q

What 3 words are universally used to describe pain

A

Pain , hurt and ache

Nursing School (36 decks)

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