Module 11 & 12 Flashcards by Haley Farstad

What is cognitive function?

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

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

can’t collaborate

- can’t control patient and nurse safety

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What is the subjective assessment of cognitive function?

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

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What is the objective assessment of cognitive function?

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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What is disorientation?

Inability to be cognizant of 1 or more of:

person
place
time

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What is the priority concern with disorientation?

SAFETY

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

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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What are the 5 senses essential to health?

tactile
hearing
taste
smell
sight

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How does sensory function contribute to health?

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

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What is the subjective assessment of sensory function?

Common concerns or injuries (COLDSPAA it)
past health history
lifestyle
age related changes

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What is the objective assessment of sensory function?

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

COMPARE SIDE TO SIDE

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what are health promotion nursing interventions for: prevent vision loss

regular check ups
enough light
taking breaks
lubrication
nutriton
contact lens use

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what are health promotion nursing interventions for: hearing loss

keep noise down

- ear plugs

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what are health promotion nursing interventions for: prevent sensory overload

less clutter
dimming light
decreased noise

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what are health promotion nursing interventions for: prevent sensory deprivation

color
lights
window
textured bedding
something tactile to stimulate

what are health promotion nursing interventions for: address visual deficits

glasses within reach
large print newspaper/books
identify yourself when entering the room

what are health promotion nursing interventions for: hearing deficits

access to hearing aids

- communication cards

What are the physical effects of acute pain?

increased BP
increased HR
increased Respiration rate
decreased O2 sat
increased GI
decreased blood flow to extremities
increased blood glucose level

What are the psychological effects of acute pain?

agitation, depression, anxiety

What are the social effects of acute pain?

isolation

What are the spiritual effects of acute pain?

questioning faith

- payment for something

What are the effects of chronic pain?

less ADLs
decreased quality of sleep
question spirituality

What is the subjective assessment for pain?

COLDSPAA

Can you objectively assess pain?

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

What should you remember about pain???

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

What are nursing interventions to relieve pain?

- 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

What are the functions of sleep?

- tissue restoration - growth hormone release - protein synthesis - decreased BMR - increased BF to brain - Increased O2 consumption by brain - epinephrine release

What are the 5 stages of sleep?

- Stage 1 NREM - Stage 2 NREM - Stage 3 NREM - Stage 4 NREM - REM

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

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

What is stage 1 NREM sleep?

- barely falling asleep | - can still be aroused

What is stage 2 NREM sleep?

- sound sleep - still have muscle tension - decreased body functions

What is stage 3 NREM sleep?

- deep sleep - relaxed muscles - when sleep walking and bed wetting occurs

What is stage 4 NREM sleep?

- deepest sleep | - vital signs really decrease

What is REM sleep

- vivd and elaborate dreams - GI secretions increase - total loss of skeletal muscle tone

How do you subjectively assess sleep?

- Common concern or injury (COLDSPAA) - Past health history - lifestyle (bedtime routine) - age related changes

What are 5 health promotion nursing interventions to promote sleep?

- 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)