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d- nursing Fundamentals > exam 3 presentations > Flashcards

exam 3 presentations Flashcards

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1
Q

acute pain

A

Rapid onset but resolves

Vital, physiological response

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2
Q

chronic pain

A

Constant or recurring pain

Normal vital signs, impacts mental well-being

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3
Q

nociceptive pain

A

Damage to body tissues

Throbbing, sharp, achy

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4
Q

Neuropathic pain

A

Damage to nerves

Stabbing, burning, shooting, pins/needle

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5
Q

intractable pain

A

Does not respond to therapy or interventions

Focus is reducing discomfort

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6
Q

phantom pain

A

Removal of limb

Burning, fiery, crushing, cramping

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7
Q

cutaneous classification pain

A

Superficial, involves skin or subcutaneous
tissue

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8
Q

somatic pain classification

A

Diffuse or scattered
*

Originates in tendons, ligaments, bones, blood
vessels and nerve

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9
Q

visceral pain classification

A

Poorly localized
*

Originates in the thorax, cranium and
abdomen

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10
Q

referred pain classifaictoin

A

Originates in one part of the body by is
perceived in a distant location

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11
Q

malignant/cancer pain classification

A

Results from direct effects of the disease and
its treatment

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12
Q

factors affecting pain

A

Past Experience / Background

Culture / Religion

Age

Family

Anxiety / Stressors

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13
Q

LOPQRST pain assess

when is it used
what does it do

A

used in beginning of assessment

Location (Where is the pain? If unable to answer, can you point?)

Onset (When did the pain start?)

Provocation (What makes it better or worse?)

Quality (How would you describe your pain?)

Radiation (Does the pain go from one place to another? Can you point to it?)

Severity (Can you rate your pain 0/10?)

Time (How long does the pain last?)

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14
Q

Numeric Scale pain assess

when is it used
what does it do

A

Used in patients above 9 who are able to use numbers correctly

give a number that correlates to pain currently

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15
Q

Wong- Baker FACES pain assess

when is it used
what does it do

A

used in patients above 3 years old that cannot use numbers

children rate pain based on :) to :( that correlates to a specific number

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16
Q

Verbal Descriptors pain assess

when is it used
what does it do

A

used in adults and children when they can process/talk through pain

used in all patients if they can, they will describe pain based on key words to narrow down how they feel

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17
Q

COMFORT Scale pain assess

when is it used
what does it do

A

children,adults/childern with cognitive impairments, ICU

each rated 1-5
alrtness
calmness
respitoary distress
crying
physical movement
muscle tone
facial tension
bp/hr

determine level on analgesic needed to adequately relieve pain in patient

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18
Q

FLACC Scale pain assess

when is it used
what does it do

A

used in infants/children from 2mon-7year who are unable to validate pain

Faces,legs,activity,cry,consalabiltiy
rate each on 0-2 scale

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19
Q

PAIN AD pain assess

when is it used
what does it do

A

Used in patients whose dementia is so far advanced that they cannot verbally communnicate

relies on: breathing, vocalization, facial expression, body language, consalability

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20
Q

non pharmelogical pain interventions

A

TENS unit
* Heat / Ice
* Repositioning
* Toileting
* Quiet Environment / Hypnosis
* Guided Imagery
* Massage / Acupuncture
* Distraction

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21
Q

phatmaolgical pain management

A

Non-Opioid Analgesics / NSAIDs
* Opioids
* Adjuvant or Co-Analgesics
* PCA Pump

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22
Q

factor affecting pain management

A

Pain Threshold

Pain Tolerance

Medication Tolerance

Breakthrough Pain

Dependence Addiction

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23
Q

Factors Affecting Sensory Function

A

AGE
CULTURE
MEDICATIONS
STRESS / ILLNESS
LIFESTYLE

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24
Q

disturbed sensory perception

A

Sensory Deprivation
Sensory Overload
Visual Impairment
Hearing Impairment
Olfactory Impairment
Tactile Impairment
Delirium
Dementia
Unconscious Patient

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25
Q

Pain Pathophysiology

A

The body gets the noxious signal from the stimuli (hot stove), sends an impulse to the spinal cord which relays the information to the brain. The brain interprets this as pain (ouch), localizes it and sends the instructions back to the body (removing hand from hot stove)

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26
Q

What does pain determine?

A

Warns the body of potential or actual injuries or diseases

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27
Q

acute pain (long)

A

Rapid onset and varies in intensity from mild to severe
–After underlying cause is resolved, pain disappears

-Body’s Response –
Increased HR/BP (fight of flight), diaphoretic (sweating), pupils normal or dilated, restlessness

28
Q

chronic pain long

A

Pain that lasts beyond the normal healing period
-Anywhere between 1 and 6 months but commonly 3 months in practice-

Can be constant, episodic (remission with exacerbation), or recurring

Body’s Response –
Normal vital signs,
restlessness w/ exacerbation,
pupils normal or dilated, poorly localized,
varies from person to person,
commonly impacts mental well-being (depression, anger, frustration, sleep/appetite disturbance)

29
Q

Nociceptive Pain
long

A

Caused by damage of body tissues

External injury: hitting elbow, falling or scrapping knee, twisting ankle, stubbing toe

Representative of the normal pain process (acute)

Locations can be visceral or somatic pain

Described as throbbing, sharp, or achy pain

30
Q

Neuropathic Pain
long

A

Caused by damage to the nerves

Peripheral (hands/feet) & central neuropathic pain (anything impacting central nervous system)

Cancer, alcoholism, stroke, limb amputation, chemotherapy drugs, radiation, or diabetes

Described as stabbing, burning, shooting, pins and needles, or sharp pain (electric shock)

Does not generally respond to conventional analgesics

31
Q

Intractable Pain
long

A

Does not respond to therapy or interventions

Degenerative spinal disease, chronic regional pain syndrome (CRPS), neuropathy, osteoporosis

Focus is reducing discomfort

32
Q

phantom pain long

A

Caused when limb is removed

No nerve endings are present but patient still feels pain in their limb

Described as burning, fiery sensation, crushing, cramping

VERY REAL and needs to be treated

Treatment: NSAIDs, pain relievers, antidepressants, beta blockers, antiseizure medications, muscle relaxers, injections, neurostimulators, spinal cord stimulators, TENS units

33
Q

Cutaneous Pain long

A

Superficial, involves the skin or subcutaneous tissue (burning).
Example: Papercut

34
Q

Somatic Pain long

A

Diffuse (spread out) or scattered. Originates in tendons, ligaments, bones, blood vessels, and nerves (bone/joint pain)

Example: Ankle sprain

35
Q

Visceral Pain
long

A

Poorly localized. Originates in the thorax, cranium, and abdomen (aching/squeezing).
Example: Bladder pain

36
Q

Referred Pain
long

A

Originates from one part in the body but is perceived in an area distant from its point of origin.

Example: Heart attack – pain is felt in the neck, shoulder, chest, or arms (usually left)

37
Q

Malignant /Cancer Pain
long

A

Results from the direct effects of the disease and its treatment

38
Q

control gate theory

A

This is the concept that non-painful input, such as a TENS unit, massage, heat, ice, or acupuncture CLOSES the gate to painful input, preventing the pain sensation from traveling to the central nervous system

39
Q

Factors that Affect Pain

A

Past experience with pain/ background

Cultural / Religious considerations

age

family

anxiety/stressors

40
Q

communication do

A

Use open ended questions

Active listening

Seeking clarification

Summarizing

Reflecting

41
Q

communication dont

A

Ask “why”

Use clichés (you’ll be just fine)

Stereotype / Judge

Give advice

Use “elderspeak” or baby talk

42
Q

How Do We Assess Pain?

A

Location (Where is the pain? If unable to answer, can you point?)

Onset (When did the pain start?)

Provocation (What makes it better or worse?)

Quality (How would you describe your pain?)

Radiation (Does the pain go from one place to another? Can you point to it?)

Severity (Can you rate your pain 0/10?)

Time (How long does the pain last?)

43
Q

Non-pharmacological Interventions

A

TENS unit
Heat/Ice
Toileting / Making Comfortable
Quiet Environment / Hypnosis
Guided Imagery
Massage / Acupuncture
Exercise or Repositioning
Distraction (laughter, music, TV)

44
Q

Pharmacological Interventions

A

Non-opioid Analgesics or NSAIDs
Tylenol or Ibuprofen

Opioid Analgesics
Mild (Tramadol)
Strong (Hydromorphone/Morphine)

Adjuvant or Co-analgesics
Medications with a primary purpose other than pain relief (antidepressants, anticonvulsants, steroids)

45
Q

pca pump

A

Patient-Controlled Analgesia
Set to administer scheduled and/or on-demand dosing

Patient must press the button
Assess who is appropriate!!!

Assess patient AT MINIMUM every 4 hours
Continuous pulse-ox d/t increased risk for respiratory depression
Two RNs must check the settings!!!

46
Q

Priority Assessments w/ Opioid Administration

A

REMEMBER, ABC!!!!!

Level of Consciousness (LOC)

Respiratory Status (rate/quality)

Side effects (nausea/constipation)

Level of pain

Vital signs

47
Q

Pain Threshold

A

Lowest intensity at which pain is experienced

48
Q

Pain Tolerance

A

Point when a patient can no longer endure the pain

49
Q

Medication Tolerance

A

Body becomes accustomed and needs a larger dose for pain relief

50
Q

Breakthrough Pain

A

Pain that occurs in-spite of medical intervention / flare-up, often use PRN medications to treat

51
Q

Dependence

A

Body becomes accustomed to opioid therapy and experiences withdrawal when stopped

52
Q

Addiction

A

Inability to stop using a substance even though it causes physical harm – used for euphoric aspect in spite of pain resolving

53
Q

Sensory Perception MOA

A

Stimuli

Stimuli is sensed and converted to nerve impulse

nerve impulsed conducted through nervous system

brain receives impulse and translate it into sensation

54
Q

Factors affecting sensory
function

A

Developmental age
* Culture
* Stress
* Medications
* Illness
* Lifestyle

55
Q

Sensory Deprivation

A

Drowsiness or Excessive
Yawning

“Escape Behaviors”

Unusual body sensations, Illusions & Hallucinations

Decreased attention span,problem-solving & ability to concentrate

Crying or irritability

Confusion

Depression & panic

56
Q

Sensory Overload

A

Fatigue

Insomnia

Sleeplessness

Anxiety

Racing thoughts

Disorientation

Increased muscle tension

Difficulty with problem
solving

57
Q

Visual sensory deficit/ impairment

interventions

A

Eye patches / surgery
* Presbyopia, Cataracts, Glaucoma, Macular Degeneration

bright colors, larger everything,enlarged text, clear pathways glasses

58
Q

Hearing Impairment

interventions

A

Other senses enhanced
Amplification of devices
Hearing aids, FM systems, Cochlear implant

read lips, decrease background noise, check batteries, talk slower

59
Q

Olfactory Impairment

A

Taught the dangers of working with chemicals

Carefully inspect food for freshness

60
Q

tactile impairment

A

May not be aware of heat/cold

May not be aware for repositioning on bony prominences = pressure ulcer

complete rom, reposition, ambulate frequently, use moisturizers

61
Q

Delirium

A

Sudden Onset

Either quiet, sleepy and
disorientated, or restless and very distressed.

Sleep may be disturbed

May hallucinate

Communicate using reality orientation

Cause: Medications, nutritional deficiency, illness, circulatory or metabolic problems – one specific cause

Interventions: Reorient frequently and immediately after surgery, structured environment, using aids (hearing/glasses) to minimize isolation and confusion, reduce the use of antipsychotics as they exacerbate the problem

62
Q

Dementia

stages
what does
causes
interventions

A

Slow Onset

Forgetfulness (early AD)
Increased confusion (middle AD)
Trouble speaking with difficulty understanding others (advanced AD)

Alzheimer’s Disease is irreversible and progressive –impacts memory and advances to inability to self-care

Communicate using validation

Causes: Alzheimer’s Disease, stroke, or vascular event

Interventions: Safety, decreased stimuli, frequent or constant supervision and care, emotional support/education/empathy with family

63
Q

Unconscious Client

who
risks
nursing considerations

A

Coma, Ventilated patient, Medication induced coma

Risk for sensory deprivation,uti

Hearing is the last sense lost
Assume the patient can hear you
Speak before touching

64
Q

kinesthesia

A

awareness of position of body parts/movements

65
Q

visceral

A

awareness of inner organs

d- nursing Fundamentals (10 decks)

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