Module 11 & 12 Flashcards
What is cognitive function?
brain function, thinking, consciousness and awareness (person, place and time IN THAT ORDER!!!)
How is cognitive function an important aspect of health for the nurse?
- can’t collaborate
- can’t control patient and nurse safety
What is the subjective assessment of cognitive function?
- Common concern or injuries? (COLDSPAA it!)
- past health history
- lifestyle
- age related changes
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)
What is disorientation?
Inability to be cognizant of 1 or more of:
- person
- place
- time
What is the priority concern with disorientation?
SAFETY
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
What are the 5 senses essential to health?
- tactile
- hearing
- taste
- smell
- sight
How does sensory function contribute to health?
SAFETY- can’t feel pain, smell a fire and see traffic etc.
What is the subjective assessment of sensory function?
- Common concerns or injuries (COLDSPAA it)
- past health history
- lifestyle
- age related changes
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
When doing any assessment of sensory, MSK what do you ALWAYs do?
COMPARE SIDE TO SIDE
what are health promotion nursing interventions for: prevent vision loss
- regular check ups
- enough light
- taking breaks
- lubrication
- nutriton
- contact lens use
what are health promotion nursing interventions for: hearing loss
- keep noise down
- ear plugs
what are health promotion nursing interventions for: prevent sensory overload
- less clutter
- dimming light
- decreased noise
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)
