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Nursing 1112 Midterm 2 > Module 11 & 12 > Flashcards

Module 11 & 12 Flashcards

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1
Q

What is cognitive function?

A

brain function, thinking, consciousness and awareness (person, place and time IN THAT ORDER!!!)

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2
Q

How is cognitive function an important aspect of health for the nurse?

A
  • can’t collaborate

- can’t control patient and nurse safety

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3
Q

What is the subjective assessment of cognitive function?

A
  • Common concern or injuries? (COLDSPAA it!)
  • past health history
  • lifestyle
  • age related changes
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4
Q

What is the objective assessment of cognitive function?

A
  • Level of consciousness (LOC)- alertness, orientation to person, place and time
  • behaviour and appearance (i.e. dress, grooming, mannerisms, language)
  • language (i.e. aphasia -can’t talk)
  • intellectual function (memory)
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5
Q

What is disorientation?

A

Inability to be cognizant of 1 or more of:

  • person
  • place
  • time
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6
Q

What is the priority concern with disorientation?

A

SAFETY

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7
Q

What are nursing interventions to promote health and safety with disorientation?

A
  • bed rails (when appropriate)
  • bed close to nursing station
  • wander guard (to keep person on the unit)
  • removing unnecessary equipment
  • call bell
  • low bed position
  • control noise
  • comfortable room temperature
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8
Q

What are the 5 senses essential to health?

A
  • tactile
  • hearing
  • taste
  • smell
  • sight
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9
Q

How does sensory function contribute to health?

A

SAFETY- can’t feel pain, smell a fire and see traffic etc.

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10
Q

What is the subjective assessment of sensory function?

A
  • Common concerns or injuries (COLDSPAA it)
  • past health history
  • lifestyle
  • age related changes
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11
Q

What is the objective assessment of sensory function?

A
  • Environmental Assessment: hearing aid, glasses, too much or too little stimuli
  • Vision assessment: glasses, read a newspaper, identify colours
  • Hearing assessment: hearing aid
  • Tactile assessment: tactile accuracy, can they touch something and identify it with eyes closed
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12
Q

When doing any assessment of sensory, MSK what do you ALWAYs do?

A

COMPARE SIDE TO SIDE

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13
Q

what are health promotion nursing interventions for: prevent vision loss

A
  • regular check ups
  • enough light
  • taking breaks
  • lubrication
  • nutriton
  • contact lens use
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14
Q

what are health promotion nursing interventions for: hearing loss

A
  • keep noise down

- ear plugs

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15
Q

what are health promotion nursing interventions for: prevent sensory overload

A
  • less clutter
  • dimming light
  • decreased noise
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16
Q

what are health promotion nursing interventions for: prevent sensory deprivation

A
  • color
  • lights
  • window
  • textured bedding
  • something tactile to stimulate
17
Q

what are health promotion nursing interventions for: address visual deficits

A
  • glasses within reach
  • large print newspaper/books
  • identify yourself when entering the room
18
Q

what are health promotion nursing interventions for: hearing deficits

A
  • access to hearing aids

- communication cards

19
Q

What are the physical effects of acute pain?

A
  • increased BP
  • increased HR
  • increased Respiration rate
  • decreased O2 sat
  • increased GI
  • decreased blood flow to extremities
  • increased blood glucose level
20
Q

What are the psychological effects of acute pain?

A
  • agitation, depression, anxiety
21
Q

What are the social effects of acute pain?

A
  • isolation
22
Q

What are the spiritual effects of acute pain?

A
  • questioning faith

- payment for something

23
Q

What are the effects of chronic pain?

A
  • less ADLs
  • decreased quality of sleep
  • question spirituality
24
Q

What is the subjective assessment for pain?

A

COLDSPAA

25
Q

Can you objectively assess pain?

A

YES- grimacing, body language but must be coupled with subjective info

26
Q

What should you remember about pain???

A

Pain is whatever the person says it is, existing whenever the person says it does!!!

27
Q

What are nursing interventions to relieve pain?

A
  • collaboration (develop a plan for pain control)
  • remove the stimulus
  • positioning
  • guided imagery
  • progressive relaxation
  • distraction
  • massage
  • warm cold applications
  • bandaging support
  • education about other therapies
28
Q

What are the functions of sleep?

A
  • tissue restoration
  • growth hormone release
  • protein synthesis
  • decreased BMR
  • increased BF to brain
  • Increased O2 consumption by brain
  • epinephrine release
29
Q

What are the 5 stages of sleep?

A
  • Stage 1 NREM
  • Stage 2 NREM
  • Stage 3 NREM
  • Stage 4 NREM
  • REM
30
Q

Can a nurse objectively observe the quality of a persons sleep?

A
  • NO (only if hooked up to machines) - can see symptoms of a bad sleep
31
Q

What is stage 1 NREM sleep?

A
  • barely falling asleep

- can still be aroused

32
Q

What is stage 2 NREM sleep?

A
  • sound sleep
  • still have muscle tension
  • decreased body functions
33
Q

What is stage 3 NREM sleep?

A
  • deep sleep
  • relaxed muscles
  • when sleep walking and bed wetting occurs
34
Q

What is stage 4 NREM sleep?

A
  • deepest sleep

- vital signs really decrease

35
Q

What is REM sleep

A
  • vivd and elaborate dreams
  • GI secretions increase
  • total loss of skeletal muscle tone
36
Q

How do you subjectively assess sleep?

A
  • Common concern or injury (COLDSPAA)
  • Past health history
  • lifestyle (bedtime routine)
  • age related changes
37
Q

What are 5 health promotion nursing interventions to promote sleep?

A
  • environmental control (noise, light, temp., smell)
  • promote routine (so body gets used to a pattern)
  • promote comfort (relieve pain, wrinkle free bed, empty bladder)
  • stress reduction ( relaxation, guided imagery)
  • bedtime snacks (low sugar, dairy products, avoid caffeine, alcohol and nicotine)

Nursing 1112 Midterm 2 (5 decks)

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