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Fundamentals Of Nursing > Mod 3 > Flashcards

Mod 3 Flashcards

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1
Q

What are kubler-Ross’s stages of grieving?

A

Denial

Anger

Bargaining

Depression

Acceptance

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2
Q

What are sources of loss?

A

Aspect self- a persons change in body image

External objects- loss of an inanimate object

Familiar environment- sepration of a enviorment and people who provide security

Loved ones-losing a loved on of valued person

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3
Q

What are the types of loss?

A

Actual - recognized by others

Perceived - experienced by one person but cannot be verified by others

Anticipatory - experienced before loss has occurred (actual/perceived)

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4
Q

Why is it important for the nurse to place the in a natural position directly after death?

A

because families often like to veiw the body in a comfortable position so you must put dentures in close the mouth and eyes before rigor mortis sets in. it will usally leave the body about 96 hours after death

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5
Q

What factors influence the loss and greiving response?

A

Age-affect the persons understand of loss

Significance ofthe loss-the importance of the lost person, oblect or function

Culture- how one greive is based off of coustoms

Spiritual beliefs

Gender

Socioeconomic status- ex insurance, pension

Support systems-many people with draw from grieving individual

Cause of death

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6
Q

what are nursing diagnoses associated with loss and grieving?

A

Grieving: a normal complex process that includes emotional, physical,spiritual and intellectual response and behaviors by which individuals, families and communities incorporate an actual, aticipated, or perceived loss into thier daily lives

Complicated Grieving/risk for complicated grieving:a disorder that occurs after death of a significant other, in which the experience of distress acompanying bereavement fails to follow normative expectations and manifest in functional impairment

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7
Q

What is grief?

A

manifested in thoughts, feelings, and behaviors associated with overwhelming distress or sorrow’

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8
Q

What is breavement?

A

is the subjective response experienced by the surviving loved ones

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9
Q

What is Mourning?

A

the behavioral process through which grief is eventually resolved or altered’

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10
Q

What are traditional clincal signs of death?

A

cessantion of

apical pulse

respirations

blood pressure

heart and lung death

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11
Q

What is the World Medical Assembly guidelines for death?

A
  • Total lack of response to external stimuli
  • No muscular movement especially during breathing
  • No reflexes
  • Flat encephalogram
  • In instances of artificial support, absence of brainwaves for at least 24 hour
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12
Q

What is Closed awareness?

A

when the client is not made aware of impending death

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13
Q

What is Mutual pretense?

A

the client, family and care provider know that the prognsis is terminal but dont not talk about it

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14
Q

What is open awareness?

A

the client and other know about the impending death and feel comfortable talking about it.

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15
Q

What rights does a dying person have?

A
  • I have the right to be treated as a living human being until I die.
  • I have the right to maintain a sense of hopefulness, however changing its focus may be.
  • I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this might be.
  • I have the right to express my feelings and emotions about my approaching death in my own way.
  • I have the right to participate in decisions concerning my care.
  • I have the right to expect continuing medical and nursing attention even though “cure” goals must be changed to “comfort” goals.
  • I have the right not to die alone.
  • I have the right to be free from pain.
  • I have the right to have my questions answered honestly.
  • I have the right not to be deceived.
  • I have the right to have help from and for my family in accepting my death.
  • I have the right to die in peace and dignity.
  • I have a right to retain my individuality and not be judged for my decisions, which may be contrary to beliefs of others.
  • I have the right to discuss and enlarge my religious and/or spiritual experiences, whatever these may mean to others.
  • I have the right to expect that the sanctity of the human body will be respected after death.
  • I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death
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16
Q

What does hospice care focuse on?

A

support and care of the dying person and family and emphasizes on improveing quality of life over treatment or cure

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17
Q

How is Palliative described by the World Health Organization?

A

is an approach that improves the quality of life of the client and families facing the problem associated with life threatening illness through the prevention and relief of suffing by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

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18
Q

What is rigor mortis?

A

is the stiffing or the body that occurs about 2 to 4 hours after death

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19
Q

What is the process of rigor mortis?

A

it starts setting in the involuntary muscles (heart,bladder) and the progresses to the head, neck and truck then into the extremities.

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20
Q

What is algor mortis?

A

is the decrease body tempture after death it drops 1.8F and causes the skin to tear easily

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21
Q

What is Livor mortis?

A

it is the discoloration of skin due to ceased blood circulation and the red blood cells breaking down relaseing hemoglobin. it apears in the lowermost or dependent area of the body

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22
Q

What actions need to be taken by the nurse after a client has passed away?

A

place the body in the suine position with plams down or across the abodmen

place a pillow underneath the head to avoid blood discoloring the face

insert dentures

close eyes

wash the body place pad under the buttocks

put a clean gown on remove jewelry (except the wedding band)

brush or comb hair

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23
Q

What type of drug preparation is liquid, powder, or foam deposited or foam in a thin layer on the skin by air pressure?

A

Aerosol spray

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24
Q

What type of drug preparation is one or more drugs dissolved in water?

A

Aqueous solution

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25
Q

What type of drug preparation is one or more drugs finely divided in a liquid such as water

A

Aqueous suspension

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26
Q

What kind of drug preparation is Caplet?

A

A solid form, shaped like a capsule, coated

and easily swallowed

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27
Q

what type of drug preparation is a Capsule?

A

A gelatinous container to hold a drug in

powder, liquid, or oil form

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28
Q

what type of drug preparation is a cream?

A

A nongreasy, semisolid preparation used

on the skin

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29
Q

What is a elixir?

A

A sweetened and aromatic solution of

alcohol used as a vehicle for medicinal

agents

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30
Q

What type of drug prepation is an extract?

A

A concentrated form of a drug made from

vegetables or animals

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31
Q

what type of drug preparation is gel or jelly?

A

A clear or translucent semisolid that liquefies

when applied to the skin

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32
Q

What type of drug preparation is liniment?

A

A medication mixed with alcohol, oil, or

soapy emollient and applied to the skin

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33
Q

What type of drug preparation is a lotion?

A

A medication in a liquid suspension

applied to the skin

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34
Q

What is a lozenge?

A

A flat, round, or oval preparation that dissolves

and releases a drug when held in

the mouth

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35
Q

what is an ointment or a slave?

A

A semisolid preparation of one or more

unction) drugs used for application to the skin and

mucous membrane

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36
Q

What is a paste?

A

A preparation like an ointment,but thicker

and stiff, that penetrates the skin less than

an ointment

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37
Q

pill

A

One or more drugs mixed with a cohesive

material, in oval, round, or flattened shapes

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38
Q

Powder

A

A finely ground drug or drugs; some are

used internally, others externally

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39
Q

What is a suppository?

A

One or several drugs mixed with a firm

base such as gelatin and shaped for insertion

into the body (e.g., the rectum); the

base dissolves gradually at body temperature,

releasing the drug

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40
Q

syrup

A

An aqueous solution of sugar often used

to disguise unpleasant-tasting drugs

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41
Q

Tablet

A

A powdered drug compressed into a hard

small disk; some are readily broken along a

scored line; others are enteric coated to prevent

them from dissolving in the stomach

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42
Q

Tincture

A

An alcoholic or water-and-alcohol solution

prepared from drugs derived from plants

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43
Q

Transdermal patch

A

A semipermeable membrane shaped in

the form of a disk or patch that contains a

drug to be absorbed through the skin over

a long period of time

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44
Q

if a primary care provider writes an incorrect order and the nurse administers the the incorrect order who is responsible for the error?

A

the nurse as well as the primary care provider. A nurse should question any order that seem unreasonable and refuse to give the medication until the order is clarified.

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45
Q

what do high alert medications require?

A

verification of two registered nurses

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46
Q

what does the therapeutic effect of drugs refer to?

A

as a desired effect it is the primary effect intended, the reason the drug is prescribed

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47
Q

What is a secondary effect of a drug that is unintended?

A

side effect, they may usually predictable and my be either harmless or potentially harmful

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48
Q

some side effects are tolerated for the drug’s therapeutic effect,but more severe side effects are called what?

A

adverse effect and my justify the discontinuation of a drug

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49
Q

what is drug toxicity?

A

the quality of a drug that exerts a deleterious effect on an organism or tissue

an example of toxic effect is respiratory depression due to the cumulative effect of morphine sulfate in the body

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50
Q

An immunologic reaction to a drug is called what?

A

drug allergy

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51
Q

what therapeutic action does palliative drugs have?

A

relieves the symptoms of the a disease but does not treat the disease itself

Morphine sulfate, aspirin for pain

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52
Q

what therapeutic action does curative drugs have?

A

cures a disease or a condition

penicillin for an infection

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53
Q

what therapeutic action does supportive drugs have?

A

supports body fuction until other treatments or the body’s response can take over

Norepinephrine bitartrate for low blood pressure: asprin for high body temp

54
Q

what therapeutic action does substitutive drugs have?

A

replaces body fluids or substances

thyroxine for hypothyroidism, insulin for diabetes mellitus

55
Q

what therapeutic action does chemotherapeutic drugs have?

A

destroys malignant cells

busulfan for leukemia

56
Q

what therapeutic action does restorative drugs have?

A

returns the body to health

vitamin, mineral supplements

57
Q

What are common mild allerigic responses?

A

Skin rash- either an intraepidermal vesicle rash or a rash typified by an urticarial wheal or macular eruption

pruritus- itching of the skin no rash

angioedema-edema due to ncrease permeability of the blood cappillaries

rhinitis-excessive watery discharge from the nose

lacrimal tearing- excessive tearing

neausea, vomiting- stimulation of these center in the brain

wheezing and dyspnea-SOB due accumulated fluids and swelling of the respiratory tissue

diarrhea- irritation of the mucosa of the large intestine

58
Q

a severe allergic reaction usually occurs immediatey after the administration of the drug is called what?

A

anaphylastic reaction

59
Q

what are the earliest symptoms of anaphylactic reaction?

A

a subjective feeling of swelling in the mouth, tongue, acute shortness of breath, acute hypertension and tachycardia

60
Q

what is a drug tolerance?

A

exists in a person who exhibits an unusally low physiological response to a drug and who require an increase doseage to maintain theraputic effect

61
Q

when the increasing response to repeated doses of a drug that occurs when the rate of administration exceeds the rate of metabolism or excretion it is know as what?

A

cumulative effect

62
Q

what is a drug interaction?

A

it occurs when the administartion of one drug before, at the same time as, or after another drug alters the effect of one or both drugs

63
Q

what is latroggenic disease?

A

a disease caused by unintentionally by medical therapy and can be a result of drug therapy

64
Q

what is synergistic effect?

A

occurs when two different drugs increase the action of one or another drugs

65
Q

what is the difference between physiological dependence/ psychological dependence?

A

physiological dependence- is due to the biochemical changes of the body

psychological dependence- is emotional reliance on a drug to maintain a sense of well-being accompanied by feeling of need/craving for that drug

66
Q

when an orally adminstered drug is absobed from the gastrointestinal tract into the blood plasma it does what?

A

its concentration in the plasma increases until the elimination rate equals the rate of absorption. This point is known as peak plasma level

67
Q

when a drug is given intravenously (IV) its level is what?

A

high immediately after administration and decreases through time

68
Q

what is the onset of action?

A

the time after administration when the body initlly responds to the drug

69
Q

what is peak plasma level?

A

the highest plasma level acheived by a single dose when the elimination rate of the drug equals the absorption rate

70
Q

what is drug half-life?

A

the time required for the elimination process to reduce the concentration of the drug to one half what it was at the initial administration

71
Q

what is plateau?

A

a maintained concentration of a drug in the plasma during a series of scheduled doses

72
Q

what is absorption?

A
  • the process by which a drug passes in to the bloodstream
  • the first step in the movement of the drug thru the body
73
Q

what is Distribution?

A
  • the transportation of a drug from its site of absorption to its site of action
  • when drug enters bloodstream, it is carried to the most vascular organs fist—-kidneys, liver, brain
74
Q

what is Biotransformation?

A
  • aka detoxification or metabolism
  • a process by which a drug is converted to a less active form
  • takes place in the liver where many drug metabolizing enzymes in the cells detoxify the drugs—producing metabolites
  • may be altered if a person is very young, is older, or has an unhealthy liver
75
Q

what is excretion?

A
  • the process by which metabolites and drugs are eliminated from the body
  • most are eliminated thru the urine from kidneys
  • some are excreted thru feces, breath, perspiration, saliva, breast milk
  • older people may require smaller doses of a drug because the drug and its metabolites may accumulate in the body
76
Q

what are different factors that can affect medication actions?

A

developmental factors-infants due to smaller size/older due to physiological changes due to ageing

gender

diet-vitamin k, found in green leafy veggies can counteract the effect of anticoagulant Warfarin (Coumadin)

environment

time of administration-some meds need food to absorb

administering iron supplement after a meal can reduce GI irritation

77
Q

what is a stat order?

A

the med is to be given immediately and only once

78
Q

what is a single order?

A
  • to be given once at a specified tim
  • at bedtime/before surgery
79
Q

what is a standing order?

A
  • may or may not have a termination date
  • carried out indefinitely until an order is written to cancel it or it may be carried out for a specified number of days
80
Q

what is a PRN order?

A

permits the nurse to give a med when in the nurses judgement the client requires it “as needed”

81
Q

what are the essential parts of a medication order?

A

Client’s full name

date and time the order is written

name of the drug to be adminstered

dosage of the drug

frequency of the administration

route of administration

signature of the person writing the order

82
Q

oral medicaion

A
  • most common
  • drug is swallowed
  • syrup- taste of meds
83
Q

sublingual medications

A
  • placed under the tongue where it dissolves
  • never be swallowed
  • example is nitroglycerin
84
Q

Buccal medication

A

a med is held in the mouth against the mucous membranes of the cheek until the drug dissolves

85
Q

rectal medication

A

placed in to the rectum

86
Q

vaginal medication

A

placed in the vagina

87
Q

topical medication

A

applied to circumscribed surface of the body; only affect are to which they are applied

88
Q

Subcutaneous

A

Into the subcutaneous tissue, just below the skin

89
Q

transdermal

A

through the epidermis via a patch

90
Q

intramusclar

A

into the muscle

91
Q

what is the process of administering medications?

A

Identify the client

  • Use 2 identifiers

Inform the client

  • Explain the action of the drug
  • Explain any side effects that could occur
  • If the clients states he doesn’t take a pill for high bp, this should indicate an alert to the nurse

Record the drug administered

  • Name of the drug
  • Dosage
  • Method of administration
  • Specific relevant data such as pulse rate
  • Exact time of admin and signature of nurse providing the med

Evaluate the clients response to the drug

  • Report clients response directly to the nurse manager and pcp
  • Must follow up
  • Anxious client may show the desired effects of a tranquilizer by behavior that reflects a lowered stress level
  • How well a client slept can measure effectiveness of a sedative
  • Effectiveness of an analgesic can be measured by how much pain the client feels
92
Q

what are the Rights of medication administration?

A

Right medication

  • Med given was the med ordered

Right dose

  • Dose ordered is appropriate for client
  • Know usual dosage range of the med
  • Question a dose outside of the usual dosage range

Right time

  • Give med at right frequency and at time ordered

Right route

  • Give med by ordered route
  • Make certain that route is safe and appropriate for client

Right client

  • Med is given to intended client
  • Check client id band with each admin of med
  • Right client educationExplain info about med to the client
  • Whey they’re receiving it, what to expect, precautions

Right documentation

  • Document med after giving it, not before
  • If time of admin differs from prescribed time, not the time on mar and explain reason and follow thru activities
  • If med is not given, document reason why

Right to refuse

  • Adult client have right to refuse any med
  • Nurses role is to ensure that the client is fully informed of the potential consequences of refusal and to communicate the clients refusal to the hcp

Right assessment

  • Some meds require specific assessment prior to administration
  • Apical pulse, bp, lab results
  • Med order may include specific parameters for administration
  • “Do not give if pulse less than 60 or systolic bp less than 100”
  • Conduct appropriate follow up
  • Was the desired effect achieved or not?
  • Did the client experience any side effects or adverse reactions?

Right evaluation

93
Q

How do you administer nasogastric/gastrostomy medications?

A

Crush a tablet into find powder and dissolve in at least 30 mL of warm sterile water

  • Cold liquids may cause client discomfort
  • Use only water for mixing and flushing
  • Some meds are mixed with other fluids such as normal saline in order to maximize dissolution
  • Nurses are encouraged to consult with a pharmacist

Sterile water is recommended for us in adult and neonatal/pediatric clients before and after medication administration

  • Don’t use tap water

Read med labels carefully before opening a capsule

  • Open hard gelatin capsules and mix the powder with sterile water

Do not administer whole or undissolved meds because they will clog the tube

Assess tube placement prior to admin of meds-auscultate-turn suction on-tape/x-ray

Before giving the med, aspirate all the stomach contents and measure the residual volume

When administering meds

  • Remove the plunger from the syringe and connect the syringe to a pinched or kinked tube
  • Prevents excess air from entering the stomach and causing distention

Put 15 ml to 30 ml (5-10 ml children) of sterile water into the syringe barrel to flush the tube before administering the first med

  • Raise or lower the barrel of the syringe to adjust the flow as needed
  • Pinch or clamp the tubing before all the water is instilled to avid excess air entering the stomach

If you are giving sever meds, administer each one separately and flush with at least 15-30 ml (5-10 children) of tap water between each medication

When you have finished administering all medications, flush with another 15-30 ml (5-10 children) of warm water to clear the tube/cold can cause GI irritation

If the tube is connect to suction, disconnect the suction and keep the tube clamped for 20-30 minutes after give in the med to enhance absorption More than an mL-ventrogluteal/less than an mL in the deltoid

94
Q

what are hazards for a developing fetus?

A

alcohol consumptions

x-rays (1st trimester)

95
Q

what are hazards for a newborn/ infant?

A

falling

suffocation in crib

choking from aspirated milk or ingested objects

burns from hot water or other spilled hot liquids

electric shock

poisoning

leading cause of deaths is accidents/suffocation

lay on their back

96
Q

what are hazards for a toddler?

A
  • physical trauma from falling-climbing out of crib-try to turn into toddler bed
  • running into objects
  • aspiration of small toys
  • getting cut by sharp objects
  • automobile crashes
  • burns
  • poisoning-the number one cause of injury/toddler proof
  • drowning-be safe around
  • electric shock-cover outlets
97
Q

what are hazards for a preschooler?

A

playground equipment

chocking, suffocations, and obstruction of airway or ear canal by foreign objects-avoid putting thing in nose

poisoning

drowning

avoid strangers

98
Q

what are hazards for adolescents?

A

vehicular (car and bike) crashes

suicides/drunk driving-prevention for

99
Q

what are hazards for an older adult?

A

falling

burns-loose sensation in their tissues

pedestrian and automobile crashes

preventions for falls-no throw rugs/environment tidy/close by assistive help

100
Q

what are some enviromental causes for falls in older adults?

A

lighting

floors

stairs

funiture

bathrooms

101
Q

what are personal cause of falls in older adults?

A

hypotension

unsteady gait

altered mental status

poor vision

foot pathology

cognitive changes

fear

102
Q

What are ways to prevent falls in a health care agencies?

A
  • encourage the client to use the call light to request assistance; ensure the light is in easy reach
  • bed In lowest position, wheels locked
  • for confused patients keep alarms readily accessible
  • client to wear nonskid footwear
  • keep areas tidy
  • UAP may assist but RN must document!
103
Q

what are the different categories for bioterrorism agents?

A

Category A is the highest risk because they:

  • can be easily spread/ transmitted from person to person
  • result in the high death rates and have the potential for major public health impact
  • might cause public panic and social disruption
  • require special action for action for the public health preparedness

Category B agents are the second highest priority because they:

  • are moderately easy to spread
  • result in moderate illness rates and low death rate
  • require specified enhancements of CDC’s labortory capacity and enhanced disease monitoring

Category C agents include emerging pathogens that could be engineered for massspread in the future because they:

  • are easily available
  • are easily produced and spread
  • have the potential for high morbidity rate and mortality rates and major health impacts
104
Q

what biologic agents have been identified by the CDC as being of the highest concern?

A

anthrax

botulism

plague

viral hemorrhagic fevers

smallpox

tularemia

105
Q

what are nursing diagnoses for safety?

A

Risk for Injury: Vulnerable to physical damage d/t environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health

Risk for falls

Risk for Latex Allergy Response

Risk for: Infection, suffocation, poisoning, trauma, vascular trauma, aspiration, adverse reaction to iodinated contrast media, impaired skin integrity, Risk for self-directed violence

Deficient Knowledge (Accident Prevention): absence/deficiency of cognitive information r/t specific topic (e.g., safety of self and others)

Readiness for Enhanced Knowledge (Accident Prevention): a pattern of cognitive information r/t a specific topic, or its acquisition, which can be strengthened

106
Q

what is a seizure?

A

Single temporary event that consists of uncontrolled electrical neuronal discharge of the bran; interrupts normal brain function

107
Q

what are the categories of seizures?

A

Partial – aka focal – involve electrical discharges from one area of the brain

Generalized – affect whole brain

108
Q

what are different seizure precautions?

A
  • Pad bed rails, head/foot of bed, of any pt who has history of seizures
  • Place oral suction equipment in room and test to be sure it is functional
  • Oxygen equipment
109
Q

What should a RN do if a seizure occurs?

A
  • remain with client and call for assistance
  • if client isn’t in bed, assist client to the floor and protect head by holding it in your lap or on a pillow
  • loosen any clothing around the neck and check
  • turn client to lateral position (side) to prevent aspiration
  • move items in env
  • don’t insert anything into clients mouth
  • time the seizure duration
  • observe the progression of seizure, noting the sequence and type of limb involvement, skin color, check pulse respirations
  • apply oxygen via mask or cannula
  • use suction if client vomits or has excessive oral secretions
  • seizure is over, assist client to comfortable position, reorient, explain what happened, provide hygiene, allow client to verbalize feelings
  • epilepticus clients may stop breathing after seizure, begin CPR immediately , then apply oxygen when breathing resumes
  • documentation of-RN
  • location/duration/status of airway/use of oxygen-time/date/generalize contractions of arms and legs lasting 25 sec./seizure padding placed on bed/cyanotic-place on left side/airway clear-suction/14-per min. Respirations-with irregular pattern/oxygen applied at 4 liters via mask/vital signs taken every 15 min/
110
Q

What is the universal sign of choking?

A

Victims’ grasping the anterior neck and being unable to speak or cough

111
Q

what should you do if the person does the universal sign for chokeing?

A
  • Ask person if they are chocking? First
  • Then Perform Heimlich maneuver
  • Abdominal thrust
  • Any obstruction must be immediately removed
112
Q

when does health care workers need to be suspicious of a possible bioterrorism attack?

A

Is there an unusual geographic clustering of illness (e.g., individuals who attended the same public event)?

Is the emergency department receiving an increase of pts with similar symptoms that suggests an infectious disease outbreak?

Is there an unusual age distribution for common disease (e.g., an increase in chickenpox-like symptoms among adults)?

Is there a large number of cases of acute flaccid paralysis, suggestive of a release of botulinum toxin?

113
Q

how often should restraints be acessed for a psych patient?

A

every 30 min

114
Q

what are two types of restrains?

A

Physical – manual method, physical/mechanical device, material, or equipment that immobilizes or reduces ability of a pt to move his arms, legs, body, head freely

EX: leather or cloth wrist/ankle restraint; soft belts or vests, hand mitts pelvic ties gerichairs and overchair tables

Chemical – using medication to control behavior or to restrict the pts freedom of movement and NOT a standard treatment for the pts medical/psychological condition

115
Q

When are restraint condisderations?

A
  • restraint may be used to ensure the clients immediate physical safety, even If the client is not violent or self-destructive
  • seclusion may only be used for the management of violent or self-destructive behavior that is an immediate threat to the clients physical safety
  • restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the client, a staff member, or others from harm
  • the type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the client, a staff member, or others from harm
  • the use of restraint or seclusion must be implemented in accordance with safe and appropriate restraint and seclusion techniques per hospital policy
  • restraint or seclusion must be discontinued at the earliest possible time
116
Q

what can decrease awareness of stimuli?

A

Narcotics

antiepileptic agents

sedatives and antidepressants

When administering these meds, the nurse is responsible for protecting the client from injury that can result from impaired sensory perception

117
Q

what drugs if taken in large doses become ototoxic and injure auditory nerve causing hearing loss that may be irreversible?

A

Aspirin, furosemide (Lasix), aminoglycosides, chemo

118
Q

what restricts blood flow to the receptor organs and the brain decreasing awareness and slowing responses?

A

Atherosclerosis

119
Q

what can impair vision?

A

diabetes

120
Q

Disease of inner ear can affect what?

A

kinesthetic sense

121
Q

Sensory deprivation

A

decrease or lack of meaningful stimuli

  • Excessive yawning, drowsiness, sleeping
  • Decreased attention span, difficulty concentrating, decreased problem solving
  • Impaired memory
  • Periodic disorientation, general confusion, nocturnal confusion
  • Preoccupation with somatic complaints such as palpitations
  • Hallucinations or delusions
  • Crying, annoyance over small matters, depression
  • Apathy, emotional liability
122
Q

when a person is unable to process the intensity of sensory stimuli it s called what?

A

sensory overload

123
Q

Who is more at risk for seneory deprivation?

A

Clients who:

Are confined in a no stimulating or monotonous environment in the home or health care agency

Have impaired vision or hearing

Mobility restrictions such as quadriplegia or paraplegia with bed rest

Unable to process stimuli (brain damage)

Emotional disorders (depression), withdraw from themselves

Limited social contact with family and friends

124
Q

who is more likely to experance Sensory overload?

A

clients who:

Have pain or discomfort

Are acutely ill and have been admitted to an acute care facility

Being closely monitored in an ICU and have intrusive tubes such as IVs, catheters, or NG/endotracheal tubes

Have decrease cognitive ability (head injury)

125
Q

How do you communicate with a viually impaired client?

A
  • Always announce your presence when entering the clients room and identify yourself by name
  • Stay in the clients field of vision if the client has partial vision loss
  • Speak in a warm/pleasant tone of voice
  • Always explain what you are about to do before touching the person
  • Explain the sounds in environment
  • Indicate when conversation has ended and when you are leaving the room
126
Q

how do you communicate with a hearing impaired client?

A
  • Convey your presence by moving to a position where you can be seen or by gently touching the person
  • Decrease background noises
  • Talk at a moderate rate and in normal tone of voice
  • Address person directly, don’t turn away in the middle of a remark or story, make sure they can see your face easily and that its well lit
  • Avoid talking when you have something in your mouth, don’t cover your mouth with your hand
  • Keep voice at same volume throughout sentence
  • Always speak clearly and accurately
  • Do not over articulate
  • Use longer phrases, which are easier to understands
  • Use “would you like a drink of water” instead of “would you like a drink”
  • Pronounce every name with care, make reference to the name for easier understanding
  • “Joan, the girl from the office”
  • Change to a new subject at a slower rate making sure the person follows the change to new subject
127
Q
A
128
Q

what should you do to prevent sensory overload?

A
  • Minimize unnecessary light, noise and distractions; provide dark glasses and earplugs as needed
  • Control pain as indicated at the level desired by client
  • Introduce yourself by name and address client by name
  • Provide orienting cues such as clocks, calendars, equipment and furniture in room
  • Limit visitors

Speak slow/ in low tone of voice and unhurried manner

Provide new info gradually to enable client to process meaning

Describe and tests and procedures to the client beforehand

Take time to discuss clients problems and correct misinterpretations

Assist client with stress reducing techniques

129
Q

how do you prevent sensory deprivation?

A
  • Encourage the client to use eyeglasses and hearing aids
  • Address client by name and touch client while speaking if it’s not culturally offensive
  • Provide a telephone, radio, tv, clock, calendar
130
Q

Dementia

A

Dementia-chronic confusion

  • Memory impairment
  • Slow, insidious
  • Chronic, gradual, irreversible
  • No change with time of day
  • Disturbed; fragmented; awakens often during the night
  • Generally normal
  • Judgement impaired; difficulty with abstraction and word finding
  • Delusions; usually no hallucinations
  • Alzheimer’s disease, multiple infarct dementia
131
Q

Delirium

A

Delirium- acute confusion

  • Acute, fluctuating change in mental status
  • Sudden, acute onset
  • Temporary; may last hours to days
  • Worsens at night
  • Disturbed; cycles often reversed
  • Fluctuates; may be alert and oriented during the day but become confused and disoriented at night
  • Disorganized, distorted; impaired attention; alterations in memory
  • Visual/auditory tactile hallucinations; misinterpretation or real sensory experiences
  • Cerebral/cardiovascular disease, infection, reduced hearing and vision, environmental changes stress, sleep deprivation, polypharmacy, dehydration
132
Q

what are nursing diagnoses associated with sensory perception?

A

Acute confusion

Chronic confusion

Impaired memory

Risk for impaired skin integrity

Risk for injury

Social isolation

Fundamentals Of Nursing (6 decks)

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