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2020 Foundations I > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Name the six defense mechanisms.

A
  • repression
  • denial
  • sublimation
  • regression
  • projection
  • displacement
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2
Q

repression

A
  • unconscious
  • employed by ego
  • keeps disturbing/threatening thoughts from becoming conscious
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3
Q

denial

A
  • blocking external events from awareness
  • refusal to experience an overwhelming circumstance
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4
Q

projection

A

attributing one’s unacceptable thoughts/feelings/motives to another person

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5
Q

displacement

A

satisfying an impulse (e.g. aggression) with a substitute object

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6
Q

regression

A

movement back in time psychologically when faced with stress

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7
Q

sublimation

A

satisfying impulse (e.g. aggression) with a substitute, but in a socially acceptable way

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8
Q

Name the three stress-induced psychological responses.

A
  • crisis
  • burnout
  • post-traumatic stress disorder (PTSD)
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9
Q

post-traumatic stress disorder

A
  • begins with acute stress disorder
  • delayed onset longer than 4 wks
  • persists longer than 1 mo
  • pt experiences flashbacks
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10
Q

burnout

A

exhaustion of physical or emotional strength, and sometimes physical illness usually as a result of prolonged stress or frustration

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11
Q

crisis

A

condition characterized by unusual instability caused by excessive stress

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12
Q

Name the five categories of stress.

A
  • distress
  • eustress
  • developmental
  • situational
  • adventitious
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13
Q

distress

A
  • damaging and can threaten health
  • physical or mental pain or suffering
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14
Q

eustress

A
  • Psychological stress that affects performance in a positive way
  • e.g., more alert, more aware of surroundings, or more enthusiastic
  • protective
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15
Q

developmental stress

A

response to life changes (e.g. graduation, role changes, etc.)

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16
Q

situational stress

A

stress resulting from major life events such as trauma, severe illness, job change, etc.

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17
Q

adventitious stress

A

stress resulting from major events such as natural disasters and crimes of violence

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18
Q

How is physiological adaptation controlled?

A

The SNS (sympathetic nervous system) tells the adrenal medullae to release catecholamines, which cause reactions in multiple body systems

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19
Q

physiological adaptation

A

fight-or-flight response

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20
Q

What effects does the fight or flight response have on the body?

A

physiological adaptation raises:

  • HR
  • RR
  • BP
  • blood sugar
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21
Q

General Adaptation Syndrome (GAS)

A
  • Hans Selye’s description of the stress response
  • “stress syndrome”
  • has three stages:
    • alarm/compensation: fight or flight
    • resistance: energy in short supply
    • exhaustion/decompensation: energy depleted
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22
Q

Name and describe Selye’s three stages of GAS.

A
  • alarm/compensation: fight or flight response
  • resistance: energy in short supply
  • exhaustion/decompensation: no longer able to maintain response to stressor; energy depleted
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23
Q

local adaptation syndrome

A
  • localized response to stress involving specific body part, tissue, or organ
  • short-term attempt to restore homeostasis
  • two types:
    • reflex pain response
    • inflammatory response
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24
Q

Name and describe the two types of local adaptation syndrome.

A
  • reflex pain response:
    • localized response of CNS to pain
    • protects from further damage
    • involves sensory receptor, sensory nerve, effector muscle
  • inflammatory response:
    • damaged cells release histamine, prostaglandins, etc.
    • capillaries leak fluid into tissues
    • edma, erythema, warmth
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25
Q

factors affecting body temperature

A
  • age
  • hormonal changes
  • exercise, activity
  • dehydration
  • illness and injury
  • recent food or fluid intake
  • smoking
  • circadian rhythm
  • stress, emotions
  • environmental conditions
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26
Q

thermoregulation

A
  • process of maintaining a stable body temperature
  • heat loss and production controlled by hypothalamus
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27
Q

What is body temperature?

A

the difference between heat produced via metabolism and heat lost to the environment

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28
Q

What body systems help regulate body temperature?

A

nervous and cardiovascular

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29
Q

Name the six sites for measuring core temperature and three sites for surface temperature.

A
  • core:
    • rectum
    • tympanic membrane
    • temporal artery
    • pulmonary artery
    • esophagus
    • urinary bladder
  • surface:
    • skin
    • mouth
    • axillae
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30
Q

guidelines for oral temp measurement

A
  • contraindicated in
    • mouth breathers
    • pts with trauma to face or mouth
  • expected: 96.8 to 100.4F (36 to 38C)
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31
Q

guidelines for measuring temperature rectally

A
  • contraindicated in pts with
    • diarrhea
    • low platelet count/bleeding precautions
    • rectal disorders
  • expected: 0.9F (0.5C) higher than oral and tympanic
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32
Q

axillary temperature measurement variance

A

0.9F (0.5C) lower than oral and tympanic

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33
Q

How does a temporal artery temperature differ from other sites?

A
  • close to rectal
  • nearly 1F (0.5C) higher than oral
  • 2F (1C) higher than axillary
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34
Q

What affects tympanic membrane temperature measurement?

A

excess earwax

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35
Q

How do we determine if a pt’s temp is elevated?

A

compare to baseline

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36
Q

How does age affect thermoregulation?

A
  • newborns
    • large surface-to-mass ratio
    • lose heat rapidly to environment
    • expected: 97.7 to 99.5F
  • older adults
    • loss of SQ fat
    • lower body temp, feeling cold
    • expected: 95.9 to 99.5F (35 to 36.1C)
    • temp can take longer to register on thermometer
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37
Q

pyrexia

A
  • fever
  • > 100F (37.8C)
  • important defense mechanism
  • results from introduction of endogenous or exogenous pyrogens to bloodstream
  • s/sx:
    • pt may feel hot
    • chills
    • sweating
    • rashes
    • organomegaly
    • painful joints
    • murmurs
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38
Q

FUO

A

fever of unknown origin

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39
Q

febrile

A

having a fever

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40
Q

afebrile

A
  • without a fever
  • apyretic
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41
Q

hyperthermia

A
  • unusually high fever
  • nursing interventions
    • prevent shivering
    • remove cooling devices if shivering begins
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42
Q

heatstroke

A
  • s/sx:
    • body temp of 104F or higher
    • headache
    • numbness and tingling
    • confusion preceding sudden onset of seizures, delirium, or coma
    • tachycardia
    • rapid RR
    • increased BP followed by hypotension
    • hot, dry, red skin
  • can cause
    • neurological damage
    • multiple organ system failure
    • death
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43
Q

heat exhaustion

A
  • acute reaction to hot, humid environment
  • excess fluid loss from the body
  • s/sx: profuse sweating, dizziness, nausea, headache, and profound fatigue
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44
Q

shivering

A
  • systemic response to cold to increase head production
  • increases energy demand
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45
Q

malignant hyperthermia

A
  • autosomal dominant disease marked by skeletal muscle dysfunction after exposure to some anesthetics
  • temps can exceed 105°F (40.5°C)
  • may be fatal
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46
Q

hypothermia

A
  • core temp below normal
  • extended exposure to cold, sometimes with frostbite
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47
Q

pain

A
  • unpleasant sensory experience associated with actual or potential tissue damage
  • can have destructive effects
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48
Q

How do we measure pain?

A

patient report

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49
Q

How is pain classified?

A
  • origin
  • cause
  • duration
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50
Q

superficial pain

A

arises from superficial structures (skin, SQ tissues)

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51
Q

visceral pain

A
  • comes from internal organs
  • can cause referred pain
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52
Q

somatic pain

A

pain in joints, bones, muscles, skin, or connective tissue

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53
Q

referred pain

A

pain felt in one part of the body that originates from damage in another part of the body

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54
Q

phantom pain

A

pain that feels like it’s coming from a body part that’s no longer there

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55
Q

psychogenic pain

A
  • pain disorder associated with psychological factors
  • pain may not match symptoms/physical condition
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56
Q

nociceptive pain

A

“normal” transmission of pain: somatic, cutaneous, visceral

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57
Q

neuropathic pain

A
  • caused by dysfunction in nervous system or nerve damage
  • sx
    • shooting pains
    • tingling
    • numbness
    • pain with normal touch
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58
Q

pain origin classifications

A
  • superficial
  • visceral
  • somatic
  • radiating/referred
  • phantom
  • psychogenic
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59
Q

classification of pain by cause

A
  • nociceptive
  • neuropathic
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60
Q

classification of pain by duration

A
  • acute
  • chronic
  • intractable
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61
Q

acute pain

A
  • short duration (≤ 6 mos)
  • sudden trauma, surgery, ischemia, inflammation
  • usually obvious cause
  • serves protective function, unless prolonged
  • usually reversible
  • mild to severe
  • may be accompanied by anxiety and restlessness
  • when unrelieved:
    • increase morbidity/mortality
    • prolong hospital stay
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62
Q

chronic pain

A
  • ≥ 6 mos (or 3 mos)
  • can be idiopathic
  • usually begins gradually and persists
  • no useful function
  • more difficult to treat
  • often accompanied by quality-of-life and functional adverse effects
    • increased health care needs
    • increased dependence on others
    • financial burden
    • fatigue
    • depression
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63
Q

intractable pain

A
  • chronic
  • highly resistant to relief
64
Q

transduction

A

activation of nociceptors by stimuli

65
Q

transmission

A

conduction of pain message to spinal cord

66
Q

pain threshold

A

point at which a person feels pain

67
Q

pain tolerance

A

amount of pain a person is willing to bear

68
Q

pain modulation

A
  • occurs in spinal cord
  • causes muscles to contract reflexively
  • moves body part away from painful stimuli
69
Q

factors that affect the pain experience

A
  • prior experiences
  • fatigue
  • genetic sensitivity
  • age
  • emotions (anxiety, fear)
  • support systems
  • coping styles
  • culture
  • communication skills
  • cognitive function
  • contributing illnesses
70
Q

assessing pain

A
  • verbal: get complete Hx of pain
    • Onset
    • Location
    • Duration
    • Character
    • Associated symptoms
    • Relieving/aggravating factors
    • Time
    • Severity
  • nonverbal
    • elevated HR, BP
    • crying
    • moaning
    • grimacing
    • guarding
71
Q

effects of pain on pt

A
  • behavioral
    • verbalization
    • vocal response
    • facial/body movements
    • social interaction
  • ADLs
    • physical deconditioning
    • sleep disturbances
    • sexual relationships
    • ability to work (outside/inside home)
72
Q

pain scales

A
  • numeric rating scale (NRS)
  • simple descriptor scale
  • Wong-Baker FACES scale
  • visual analog scale
  • FLACC scale
73
Q

FLACC

A
  • Face
  • Legs
  • Activity
  • Cry
  • Consolability
74
Q

risk factors in pain management

A

undertreatment

  • cultural/societal attitudes
  • lack of knowledge
  • fear of addiction
  • exaggerated fear of respiratory depression
  • populations at risk
    • infants
    • children
    • older adults
    • pts with substance use disorder
75
Q

undertreatment of pain

A
  • serious health care problem
  • can lead to physiological and psychological concerns
76
Q

physiological effects of unrelieved pain

A
  • prolonged stress response
  • increased HR, BP, O2 demand
  • decreased GI motility
  • immobility
  • decreased immune response
  • delayed healing
  • unrelieved acute can lead to chronic
77
Q

hyperalgesia

A

heightened sense of pain

78
Q

allodynia

A

condition in which pt experiences pain after experiences that are not usually painful

79
Q

non-pharmacological pain management treatments

A
  • cutaneous stimulation
    • transcutaneous electrical nerve stimulation (TENS)
    • acupuncture
    • acupressure
    • massage
    • hot or cold therapy
  • immobilization and rest
  • cognitive-behavioral
    • distraction: ambulation, deep breathing, games, TV
    • relaxation: meditation, yoga
    • guided imagery
    • hypnosis
    • therapeutic touch
    • humor
    • journaling
80
Q

What kinds of therapies an effective pain management plan include?

A

pharmacological and non-pharmacological

81
Q

gate control theory

A

gating mechanism in spinal cord allows pain signals to reach brain

82
Q

heat therapy

A
  • increases blood flow by dilating blood vessels
  • best for chronic pain, dull and achy
  • leads to increased flexibility and mobility in muscles and joints
  • dry or moist: heating pad, hot pack, steamed towel, steam bath
83
Q

cold therapy

A
  • reduces blood flow by constricting blood vessels
  • use within 72 hrs of acute injury
  • reduces inflammation and pain, aiding healing
  • ice packs, frozen gel packs, ice baths
84
Q

pharmacological treatments for pain

A
  • non-opioid analgesics: for mild to moderate pain
    • NSAIDs
    • acetaminophen
  • opioid analgesics: for moderate to severe pain
    • IV, transdermal, epidural routes
    • patient-controlled analgesia (PCA) pump
    • monitor for adverse effects
  • adjuvant analgesics (coanalgesics): enhance effects of opioids; useful for neuropathic pain
85
Q

adverse effects of opioids

A
  • sedation
  • respiratory depression
  • orthostatic hypotension
  • urinary retention
  • N&V
  • constipation
86
Q

non-opioid analgesics

A
  • for mild to moderate pain
  • NSAIDs
  • acetaminophen
87
Q

opioid analgesics

A
  • for moderate to severe pain
  • IV, transdermal, epidural routes
  • patient-controlled analgesia (PCA) pump
  • monitor for adverse effects
88
Q

adjuvant analgesics (coanalgesics)

A
  • enhance effects of opioids
  • help alleviate other manifestations that aggravate pain
  • useful for neuropathic pain
  • includes
    • anticonvulsants
    • antianxiety agents
    • tricyclic antidepressants
    • anesthetics (lidocaine)
    • antihistamine
    • glucocorticoids
    • antiemetics
    • bisphosphonates and calcitonin (for bone pain)
89
Q

pharmacological management of chronic pain

A
  • long-acting or controlled-release opioid (including transdermal)
  • administer around the clock instead of PRN
90
Q

Joint Commission pain policy

A
  • pain is fifth vital sign
  • document
    • pain assessment
    • follow-up within 1 hr of PO pain med admin
    • reassess in 30 min for IV pain med
  • goal should be 0-3 on 0-10 scale
  • effectiveness determined by pt
91
Q

administering pain meds

A
  • separate Rx’s can be written for mild, moderate, or severe
  • use judgment to pick Rx based on pt data
92
Q

STAT Rx for pain

A

must be given within 30 min

93
Q

nursing action for uncontrolled pain

A

if pain isn’t controlled by Rx’s, notify provider

94
Q

placebo

A
  • any med, procedure, etc. that produces an effect on the pt because of intent, not physical or chemical properties
  • appropriate in research (informed consent)
  • NEVER give placebo to pt
  • contact supervisor if you’re told to give a placebo
95
Q

pain center

A

treat pts on inpatient or outpatient basis

96
Q

palliative care

A

goal: live life fully with an incurable condition

97
Q

hospice care

A
  • end-of-life care focused on comfort
  • ANA supports aggressive treatment of pain and suffering even if it hastens death
98
Q

allopathy

A
  • conventional western medicine/treatment
  • treats pathologies and symptoms
99
Q

holism

A
  • treats whole person
  • preventative strategies
  • lifestyle changes
  • optimal wellness
100
Q

modality

A
  • method of treating a disorder
  • traditional: abx, surgery
  • holistic
    • complementary: used with traditional
    • alternative: used instead of traditional
101
Q

integrative healthcare

A

encompasses all treatment modalities

102
Q

CAM categories

A
  • whole medical systems (traditional Chinese, homeopathy)
  • biological and botanical (diets, herbs, probiotics)
  • mind-body therapies (acupuncture, meditation)
  • energy therapies (reiki, therapeutic touch, magnet therapy)
  • movement therapies (pilates, dance)
103
Q

practitioners of complementary and alternative medicine

A
  • acupuncture
  • acupressure
  • homeopathic
  • naturopathic
  • chiropractic
  • massage
  • biofeedback
  • therapeutic touch
104
Q

natural products and herbal remedies

A
  • natural: herbal medicines, minerals and vitamins, essential oils, dietary supplements
  • herbal: plant sources; oldest form of medicine
  • not regulated by FDA
  • commonly used substances can have interactions with prescription meds
105
Q

aloe

A

used for wound healing

106
Q

chamomile

A
  • anti-inflammatory
  • calming
107
Q

echinacea

A

enhances immunity

108
Q

garlic

A

inhibits platelet aggregation

109
Q

ginger

A

antiemetic

110
Q

ginkgo biloba

A

improves memory

111
Q

ginseng

A

increases physical endurance

112
Q

valerian

A
  • promotes sleep
  • reduces anxiety
113
Q

nursing actions for CAM

A
  • understand therapies and safety precautions
  • be receptive
  • identify pt’s needs for CAM, values, preferences
  • incorporate CAM into care plan
  • evaluate pt’s responses to CAM
  • determine possible interactions with Rx meds and therapies
114
Q

pre-op care

A
  • from the time a pt is scheduled for surgery until care is transferred to OR
  • assessment of risk factors
  • thorough assessment of pt’s physical, emotional, psychosocial status
115
Q

reasons for surgery

A
  • diagnostic
  • curative
  • restorative
  • palliative
  • cosmetic
116
Q

urgency of surgery

A
  • elective: nonacute problem
  • urgent: prompt intervention required
  • emergent: immediate intervention, life-threatening
117
Q

degree of risk of surgery

A
  • minor: no significant risk, often local anesthesia
  • major: greater risk; longer and more extensive
118
Q

extent of surgery

A
  • simple: only affected areas involved
  • radical: extensive beyond obviously involved area; finding root cause
  • minimally invasive (MIS): endoscopy
119
Q

Whose responsibility is it to obtain consent before surgery?

A

the provider’s

120
Q

What information can the nurse discuss with a pt before surgery?

A

clarification of info already discussed by the provider

121
Q

What is the nurse’s role in obtaining consent?

A
  • witness signing of forms
  • ensure client is legally capable of providing consent
  • pre-op nurse must verify informed consent is complete/witnessed (notify provider and nurse manager)
  • make sure surgical site is marked by surgeon
122
Q

informed consent

A
  • required for
    • surgery
    • invasive procedures
    • things requiring sedation or anesthesia
    • radiation
    • anything that increases risk for complications
123
Q

risk factors for surgery-related complications

A
  • obstructive sleep apnea
  • pregnancy
  • respiratory dz
  • CV dz
  • DM
  • liver, kidney dz
  • endocrine disorders
  • immune system disorders
  • coagulation defect
  • malnutrition
  • obesity
  • some meds
  • substance use
  • family Hx
  • allergies
  • advanced age
124
Q

pre-op assessment

A
  • detailed Hx
  • allergies
  • anxiety level
  • baseline data
  • venous thromboembolism (VTE) risk
125
Q

risk factors for surgery complication

A
  • UA
  • blood type and cross match
  • CBC
  • pregnancy test
  • clotting studies
  • electrolyte levels
  • creatinine and BUN
  • ABGs
  • CXR
  • 12-lead ECG
126
Q

pre-op pt education

A
  • understand purpose/effects of pre-op meds
  • be aware of post-op pain control techniques
  • splinting, coughing, deep breathing, incentive spirometry
  • ROM exercises and early ambulation
  • antiembolism stockings and SCDs
  • purpose of invasive lines during and after surgery
  • post-op diet
  • pain scale
  • avoid smoking, alcohol, illicit drug use
127
Q

intraoperative care

A

from the time pt enters OR to time of transfer to PACU or ICU

128
Q

risks to pt in intra-op period

A
  • infection
  • skin breakdown
  • anxiety
  • ineffective thermoregulation
  • injury related to positioning
129
Q

members of the surgical team

A
  • surgeon
  • surgical assistant
  • anesthesia providers
  • perioperative nursing staff
    • holding area nurses
    • circulating nurses
    • scrub nurses and/or techs
    • specialty nurses
130
Q

circulating nurse duties

A

coordinate, oversee, conduct pt care while in OR

131
Q

What are the three zones of an OR?

A
  • unrestricted
  • semi-restricted
  • restricted
132
Q

What conditions exclude an employee from participating in a surgery?

A
  • open wound
  • cold
  • infection
133
Q

attire for OR

A
  • change in locker room
  • wear hospital-laundered scrubs
  • cover all hair and facial hair
134
Q

Who performs a surgical scrub before surgery?

A
  • surgeon
  • assistants
  • scrub nurse
135
Q

counting in the OR

A

performed before, during, at first layer of closure and immediately before final closure

136
Q

What is considered sterile after gowning and gloving?

A
  • front of gown from chest to level of sterile field
  • sleeves from 2 inches above elbow to cuff
  • NOT back of gown
137
Q

What responsibilities does every member of the surgical team have?

A
  • ID of pt
  • assessment
  • med record review (advance directives, DNR)
  • surgical consent verification
  • validate correct site/side with pt (time out if not)
  • allergies and previous reactions to anesthesia or transfusions
  • autologous blood transfusion
  • lab and diagnostic test results
  • Hx and physical exam: any threats to pt safety
138
Q

contraindications for receiving propofol

A

allergies to eggs and soybean oil

139
Q

3 phases of general anesthesia

A
  • induction: IV access, admin of pre-op meds, securing of airway
  • maintenance: performance of surgery, airway maintenance
  • emergence: completion of surgery, removal of assistive airway devices
140
Q

What should you do if perioperative hypotension occurs?

A
  • lower HOB
  • give IV fluid bolus
  • monitor
  • notify surgeon and anesthesiologist of abnormalities
141
Q

anesthesia complications

A
  • malignant hyperthermia
  • anesthetic toxicity
  • unrecognized hypoventilation
  • intubation problems
  • anesthesia awareness
142
Q

What drug is used to counteract malignant hyperthermia?

A

dantrolene (Dantrium)

143
Q

what to do if MH occurs

A
  • help stop surgery
  • give IV dantrolene
  • give 100% O2
  • get ABGs and potassium level
  • infuse iced IV normal saline
  • apply cooling blanket
  • apply ice to axillae, groin, neck, head
  • iced lavage
  • monitor cardiac rhythm and treat dysrhythmias
  • transfer to ICU
144
Q

What type of drug prolongs the effects of and reduces risk of systemic toxicity with local anesthetics?

A

vasoconstrictor (usually epinephrine)

145
Q

How often do you document vitals after moderate sedation?

A

every 15-30 min until pt is awake, alert, and oriented with VS at baseline levels

146
Q

nursing duties in PACU

A
  • monitor
    • respiratory, circulatory status
    • LOC, VS, O2 sat: every 15 min until stable
  • examine surgical area
  • heated blankets for hypothermic pt
  • assess return to consciousness (general)
  • assess return of motor function (local/regional)
  • discharge from unit
147
Q

expected O2 sat after surgery

A

> 92%

148
Q

hypervolemia s/sx

A
  • bounding pulse
  • SOB
  • orthopnea
  • crackles
149
Q

hypovolemia s/sx

A
  • anxiety
  • restlessness
  • tachycardia
  • tachypnea
  • cool, clammy skin
  • delayed cap refill
  • decreased UOP
150
Q

opioid overdose interventions

A
  • give naloxone hydrochloride 1-2 mg IV
  • repeat every 2-3 min up to 10 mg depending on response
  • maintain airway
  • O2 if hypoxic
  • get suction ready in cause of vomiting
  • DO NOT leave pt alone
  • monitor every 10-15 min for 1 hr until stable
  • assess for naloxone SE
151
Q

post-op pt is NPO until what functions occur

A
  • gag reflex returns
  • peristalsis resumes (flatus and/or BM)
152
Q

surgical site drainage progression

A
  1. sanguineous
  2. serosanguineous
  3. serous
153
Q

When do you monitor wound drains?

A

when taking VS

154
Q

gastroparesis

A

delayed stomach emptying

155
Q

criteria for discharge

A
  • pt can
    • take fluids orally and safely
    • ambulate to bathrom with assistance
  • significant other to accompany pt
  • Aldrete score 8-10
  • stable VS
  • no evidence of bleeding
  • return of reflexes: gag, cough, swallow
  • minimal to moderate wound drainage
  • UOP ≥ 30 mL/hr
156
Q
A

2020 Foundations I (4 decks)

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