Nursing 2700 Fundamentals: Exam Two Flashcards
What are some aspects of nursing that require critical thinking skills?
Complex situations
Unique clients
Need for holistic care
Medication administration
Definition: reasoned thinking, openness to alternatives, ability to reflect, and desire to seek truth
Critical thinking
Critical thinking skills are a _____ process
Cognitive
Critical thinking attitudes are a ____ trait
Feelings
What are some critical thinking attitudes?
Independent thinking Intellectual curiosity Humility Empathy Courage Perseverance Fair-mindedness
What are the phases of the nursing process?
Assessment Diagnosis Planning outcomes Planning interventions Implementation Evaluation
What is a comprehensive assessment?
Holistic information about the overall health status
What is a focused assessment?
Obtaining data about a suspected or identified problem or potential problem
What is meant by subjective data?
Anything the patient says
Anything you gather from family or community statements
Emotion based statements
What is meant by objective data? Give examples
Gathered through assessment or tests, things that can be measured or observed
Examples: vital signs, blood work, x-rays
What is primary data?
Subjective or objective data that you got directly from the patient
What is secondary data?
Data from a non patient source, like family members or the medical chart/record
What is a nursing diagnosis?
A statement of health that the nurse can identify, prevent, or treat independently
A nursing diagnosis is stated in terms of…
Human response to disease, injury, or stressors
What is included in a nursing diagnosis?
Problem, etiology, and intervention
What is a medical diagnosis?
Assignment of disease, illness, or injury
What is a collaborative problem?
Physiological complications (recognized by doctors) that nurses monitor to detect onset or change in status
What are the five types of nursing diagnosis?
Actual Risk/potential Possible Syndrome Wellness
Define etiology
Factors causing or contributing to problem
What are some different types of etiologies?
Pathophysiological, treatment related, situational, social, spiritual, maturational, environmental
What are the four parts of a NANDA-I nursing diagnosis?
Diagnostic label
Definition/defining characteristics (S&S)
Related to/risk factors (etiology)
Associated conditions
How does the PES format for writing nursing diagnoses work?
Problem
Etiology
Signs/Symptoms
What is a patient goal as pertains to the nursing diagnosis?
A broad statement based on the nursing diagnosis that is realistic for the patient
What are some defining characteristics of patient outcome statements?
Has steps Short term/within defined time frame Measurable Realistic Patient centered (“patient will...”)
How is a nursing intervention defined?
Evidence based actions rooted in clinical knowledge and nursing judgement to achieve client outcomes
What is an independent nursing action?
Something the RN can prescribe/perform/delegate based on knowledge and skills without a doctors order
What is a dependent nursing intervention?
Action prescribed by physician/APN but carried out by the nurse
What is a collaborative intervention?
Intervention carried out with multiple health care team members
What are some characteristics of written nursing interventions?
Nurse focused (“Nurse will...”) Realistic Relates to diagnosis and desired outcome Action statement Says how and when Rationale
What is included in evaluating a nursing care plan?
Reassessment of patient Comparison to previous data Progress made? Documentation Decision about continuing care plan
What developmental factors should be considered when looking at the environmental safety of a preschool child?
Lack of balance = falls
Unable to swim = drowning
Lack of coordination = injury
Like to put things in mouth = choking hazard
What is the number one overall cause of death in the US?
Poisoning
What is the main cause of injury in the adolescent period?
Motor vehicle accidents
What things make older adults more injury prone?
Reduced strength and flexibility
Sensory losses
Slower reflexes
What are some potential poisons that could be ingested by children?
Chemicals
Medicines
Vitamins
Cosmetics
KEEP MEDICATIONS AND FIREARMS LOCKED UP
…
What are some sources of carbon monoxide?
Gas ranges and ovens
Running cars in closed spaces
What are major contributing factors to injuries in motor vehicle accidents?
Failure to use seatbelts Failure to use correct car seats Speed Alcohol Distraction Having children in the front seat (airbags)
What are some steps to avoid food poisoning?
Make sure meat is fully cooked
Cool cooked food properly
Throw away leftovers after 3-5 days
Watch older/homeless patients for food hoarding
What are typical causes of fire in a healthcare setting?
Anesthesia
Improperly grounded or malfunctioning medical equipment
What measures should be taken, in what order, if a fire occurs?
Move patient to safety
Sound alarm
Try to confine fire
What is the RACE acronym in case of a fire?
Rescue
Alarm
Confine
Extinguish and/or evacuate
What are some things healthcare workers can do to reduce exposure to radiation?
Follow correct standards for time, distance, and shielding when it comes to radiation exposure
How can one reduce equipment related injuries in the healthcare facility?
Make sure you know how to use it
Inspect before using
Pay attention to signage
Follow policy
What assessment tool looks at ability to live alone and perform ADLs safely?
Safety assessment scale
What are the risk factors identified by the Morse Fall Scale?
History of falls Multiple medical diagnoses Ambulatory aids IV line or saline lock Change in gait Mental status
What are some assessment tools to see if an older adult needs a comprehensive falls evaluation?
Safety assessment scale
Get up and go test
What are some risk factors for burns in children?
Pot handles turned towards front of stove
Improperly heated bottles
Cooking while holding children
Improper bath temperatures
What are some ways to reduce possibilities of fire in the home?
Smoke detector
Inspect electrical cords for damage
No open flame near oxygen
The best thing to do when working in an environment with toxins is…
Shower and change before leaving work or remove work clothes before entering the house
What are the guidelines for using restraints?
Must be removed every 2 hours
Nurse must assess patient every two hours when restraints removed
Patient should be given fluid and allowed to use bathroom every 2 hours
Range of motion every 2 hours
Get patient comfortable before putting restraints back on
What specifically must the nurse assess when restraints are removed?
Presence of edema Capillary refill Sensation Function Skin integrity Erythema Pain Readiness to come out of restraints
DOCUMENT ON PATIENTS WITH RESTRAINTS AT LEAST EVERY TWO HOURS
DO NOT FORGET THIS
Are mittens considered restraints?
Yes
What are medical restraints and in what situations would they be used?
Soft limb restraints for clients pulling at IV tubes and lines
How often must medical restraints be removed and documented?
Every two hours
If a patient is incredibly strong but only needs medical restraints, what can be done?
Violent restraints can be used
Is an isolation room a proper substitute for a patient who needs restraints?
Yes, if they are non violent, but the camera looking at the room must be continually monitored
When are pelvic restraints used?
When the client is at risk for falls due to poor safety judgement
How often must pelvic restraints be documented, assessed, and removed?
Every two hours
When are violent restraints used?
When patients are combative and might cause harm to self or others and all other options have already been tried
What are guidelines for assessing and documenting with violent restraints?
They must be documented and assessed every fifteen minutes, and someone must be with the patient continually for the first hour after putting restraints on
What are guidelines for removing violent restraints?
Always approach the patient with at least two healthcare workers
Take them off one at a time
LPN or CNA can remove the restraints if the RN is present
Healthcare workers must be certified to handle these patients
What is the role of the joint commission?
Set standards to promote patient safety and help identify risks
What is the role of the Institute of Medicine as pertains to safety?
Assess healthcare related deaths/incidents
What are some examples of “never events”?
Artificial insemination with wrong donor sperm or egg
Death or disability due to error (medication, blood transfusion, falls, contaminated equipment, etc)
Death or injury to staff d/t assault
Sexual assault
What percentage of nurses report chronic back pain?
52%
What are some other common safety issues/injuries faced by nurses?
Needlestick injury
Radiation injury
Ebola/highly contagious diseases
How is Ebola transmitted?
Direct contact with body fluids
Exposure to objects contaminated with body fluids
What is to be done with suspected/confirmed hemorrhagic fever cases?
ISOLATE
And keep suspected and confirmed separate
The fifth leading cause of death in the US is…
Unintentional injuries
What are the top causes of unintentional death?
Motor vehicle accidents
Poisoning
Falls
When do most fatal home fires occur?
When people are asleep
What percentage of falls occur in the home?
More than half
What percentage of falls involve people older than 65?
About 80%
How often must medical prescriptions for restraints be renewed?
Every 24 hours
What might early identification of patient anxiety do?
Prevent the patient from becoming aggressive
How does the Heimlich differ from the American Red Cross choking rescue?
Red Cross includes back blows, heimlich does not
Decreased sensation puts elderly patients at risk for…
Burns and sunburns
If a patient verbalizes a suicide plan, the nurse should…
Not leave the room until someone else comes to assess and help
Pay attention to everything in the surroundings and how the patient could use it
A handoff report is also called…
Change of shift report
What is the purpose of a handoff report?
To promote continuity of care
When it comes to interdisciplinary communication, what has been proven to improve patient outcomes?
Nurses having input on patient care
What was found to be the root cause in 65 to 70 percent of patient care errors?
Communication issues
What information is given during the handoff report?
Patient name, doctor, and condition(s) Changes in status or condition Upcoming activities/procedures Current medications and last doses Concerns and things that need follow up
What is the drawback of a face to face oral report?
Patient is not directly observed
What is the disadvantage of an audio-recorded report?
Time consuming
No ability to ask questions of the nurse
Things may have changed since it was recorded
What are the benefits of a bedside report?
Nurse can meet patient and start assessment
Patient is included in the process and can ask questions
With each handoff, there is a risk for…
Error
What does PACE stand for and what is it used for?
It is a standardized format for reporting Stands for.. Patient/Problem Assessment/Actions Continuing/Changes Evaluation
Why is SBAR so useful?
It’s a standardized way to communicate what’s most important, especially in critical/emergency situations
When is a transfer report given?
When a patient is transferred from one unit to another or one facility to another
Who is especially vulnerable to risks/errors when transferring facilities?
Older adults
What does MBAR stand for and when is it used?
Used during transfer reports Stands for... Medication Background Assessment Recommendation
What does SBAR-R stand for and when is it used?
It’s SBAR with a read-back component and its used when taking verbal or telephone orders from a physician
In what situations would a telephone order be acceptable?
Sudden change in patient condition
Emergency
Primary doctor not at hospital
Doctor doesn’t have access to internet to put in order
What should the nurse include when recording a verbal order?
Date, time, written text or electronic entry of the order. Indicate “VO” with the physicians name and your name
What are the legal and ethical responsibilities of the nurse as pertains to physicians orders?
If you believe it is inappropriate or unsafe, you are legally/ethically required to question it.
you are allowed to refuse orders if uncomfortable — just report up the chain of command
What are some key elements to teamwork?
Clearly defined roles Respect for one another Good communication Decision-making procedures are clear Non-punitive environment
Nurses feeling free to speak and voice concerns has been proven to lead to…
Better patient outcomes
What are some barriers to effective interdisciplinary communication?
Personalities Differing values Hierarchy Cultural differences Generational differences Gender differences
What are the benefits of nurses participating in patient rounding?
Nurse can provide input
Improves nurse/doctor relationships and professional satisfaction
What is CUBAN used for?
Used as a guideline for how report should be given
What does CUBAN stand for?
Confidential Uninterrupted Brief Accurate Named nurse
How should the nurse always end an oral report?
Ask if receiving nurse has any questions
What are some guidelines for receiving telephone orders?
Have another nurse listen to verify accuracy
Only do it if you heard it firsthand
Spell back medications and say numbers as individual digits
Repeat back the order
What does “TO” stand for?
Telephone order
What does “VO” stand for?
Verbal order
How quickly must a telephone or verbal order be signed by practitioner?
Within 24 hours
What is the difference between a handoff report and a transfer report?
Transfer report is more detailed
What should be included in a transfer report?
Patient name, demographics, diagnoses, reason for transfer
Family contacts
Summary of care
Current status (medications, treatments, tubes, times for meds)
Wounds/open areas
Special directives
Code status, intensity of care, isolation
Your contact information
What are morals?
Beliefs or convictions of an individual or a group that are learned and developed across the lifespan
What are ethics?
A formal process for deciding right and wrong conduct in situations where issues of values/morals arise. Process for making consistent moral decisions
What does nursing ethics refer to?
Ethical questions that arise out of nursing practice
What is ethical agency?
Ability to make ethical choices and be responsible for one’s ethical actions. Being able to follow through on ethical decisions
What is moral distress?
The inability to carry out moral decisions. Difficulty choosing between options because of morals
Identifying incompetent, unethical, or illegal factors in a work situation and bringing it to the attention of someone who may have the power to stop it is called…
Whistleblowing
What are four factors that contribute to the frequency of nurses ethical problems?
Technological advances
Multicultural population
Cost containment in healthcare
Increasing consumer awareness
What are some factors that affect someone’s ethical decision making?
Developmental stage
Values
Ethical framework/principles
Professional guidelines
Mental dispositions towards a person, object, or idea are…
Attitudes
Something that one accepts as true is a…
Belief
A belief about the worth of something is a…
Value
How are values transmitted?
Social interaction
What is meant by value neutrality?
We know our own values regarding issues and know when to put them aside to become non-judgmental
What are six important ethical principles?
Autonomy Nonmaleficence Beneficence Fidelity Veracity Justice
Autonomy
A person’s right to choose and act on that choice
Non-maleficence
Doing no harm
Beneficence
Doing good
Fidelity
Duty to keep promises
Veracity
Duty to tell truth
Justice
Obligation or duty to be fair
What do consequentialist theories state?
The rightness or wrongness of an action depends on the consequences of that action
What does the principle of utility state about “good”?
Good acts produce the greatest good for the greatest number of people
What is believed under deontological theory?
An action is objectively right or wrong, regardless of the outcome
What is focused on by feminist ethics?
Individual stories
Social issues
Virtues like love and caring
What is the focus of an ethics-of-care?
Patients specific needs in a specific situation
Feelings emphasized, but not at the expense of ethical principles
What are some trustworthy standards for nursing ethical guidance?
Professional codes of ethics
Standards of practice
Patient care partnership
Which ethical principle underlies informed consent?
Autonomy
What is values clarification?
Becoming conscious of and naming ones values
What is an ethical dilemma?
A moral problem in which a decision must be made between two equally undesirable outcomes with no clear right or wrong choices
What is the MORAL acronym used for?
Working through an ethical dilemma
What does MORAL stand for?
Massage the dilemma Outline the options Resolve the dilemma Act on chosen option Look back and evaluate
What will a good compromise do in an ethical situation?
Preserve the integrity of all parties
What are four reasons of why nurses should be patient advocates?
- The role requires it
- They have special knowledge that the patient doesnt have
- They have a special relationship with patients
- They have an obligation to defend patients autonomous decisions
How is bioethics defined?
The application of ethics to healthcare
Altruism
Concern for the well-being of others
Human dignity
The worth, uniqueness, and value of people
Integrity
Acting within a code of ethics
Social justice
Upholding moral, legal, and humanistic principles for the greater interest of groups and populations
What are the ethical principles involved in a given ethical situation?
Autonomy Non-maleficence Beneficence Fidelity Veracity Justice
What are the nurses obligations in an ethical decision?
Be sensitive to the issue Take responsibility for moral actions Work as a team member Support patient Support decisions ADVOCATE
What is moral outrage?
Belief that others are acting immorally and feeling powerless to do anything about it
Before whistleblowing, one should…
Have the facts
Go up the chain of command
Think about possible consequences
A binding practice, rule, or code of conduct that guides a community or society and is enforced by authority is…
Law
Where does the right of privacy come from?
The Bill of Rights
What is a durable power of attorney?
A person who will make decisions for a patient if the patient becomes unable to do so
What are some state laws that affect nursing practice?
Mandatory reporting laws
Good Samaritan laws
Safe harbor laws
Nurse practice acts
What is outlined by the ANA code of ethics?
Standards of professional responsibility for nurses
What ethical and acceptable behavior looks like
What is outlined in the ANA Bill of Rights?
Rights nurses should expect from their workplace and work environment in order to practice as a professional
What is a primary thing that encourages competence and adherence to standards of practice in healthcare providers?
Medical malpractice system
What do standards of practice say?
What a reasonable and prudent nurse would do in the same or similar situations
What is established by state boards of nursing to govern nursing practice?
Nurse practice acts
What are nurses mandated to report?
Suspected or actual abuse
Impaired health professionals
Communicable diseases
What are state boards of nursing allowed to do?
Approve pre-licensure nursing education programs
Set licensure criteria
Define nursing practice
Establish grounds for disciplinary actions
What does HIPAA do for patients?
Ensure privacy and confidentiality of medical records
Protect coverage for people with pre-existing conditions
Establish privacy standards
Which act established the guidelines for living wills and durable power of attorney?
Patient Self-Determination Act
What else does the Patient Self-Determination Act allow patients to do?
Make their own medical decisions after being fully informed about benefits and risks
When acting under Good Samaritan laws, what should a nurse do?
Don’t leave the patient
Call 911
Give patient to EMS as soon as they arrive
Can a nurse be punished for violating ANA Standards of Care?
Yes
What is an intentional tort?
Action with intent to harm
What is an unintentional tort?
Action that causes harm but was not meant to do so
What are some common malpractice claims?
Failure to assess and diagnose
Failure to implement plan of care
Failure to evaluate
What are some strategies to minimize liability in nursing practice?
CHART EVERYTHING Report errors quickly Assess/diagnose properly Delegate properly Evaluate Check meds
What is fraud?
False representation of facts
Laws made by judges or courts
Common law
Laws dealing with wrongs or offenses against society
Criminal law
Felony
Crime punishable by more than one year in jail
Law involving disputes between two entities
Civil law
What is assault?
Patient placed in fear of immediate harm (words of intent included)
What is battery?
Harmful physical contact or unauthorized touching
Is doing a procedure without consent assault or battery?
It is both
Restraining someone without legal authority is…
False imprisonment
What is spoken or verbal defamation of character?
Slander
What is written defamation of character?
Libel
What is defamation?
False communication about someone to a third person
What kind of torts are slander and libel?
Quasi-intentional torts
What is negligence?
Failure to provide orderly and reasonable care
What is malpractice?
Negligence in a professional setting
Can a nurse back out of a staffing assignment once she has received report?
No
If the situation is unreasonable or unsafe, she cannot accept it and then back out/leave
What elements are necessary to collect damages?
Existence of duty
Breach of duty
Causation
Damages
What are the three basic functions of the neurological system?
Sensory
Integration
Motor
What are the reflexes that are present at birth but disappear during infancy?
Rooting Sucking Palmar grasp Tonic neck reflex Moro Stepping reflex
What would it indicate if the reflexes present at birth Either doesnt disappear or does reappear in a later developmental stage?
Stroke
Trauma
Severe neurological problems
What is the normal neurological screening test used on young children?
The Denver Developmental Screening Tool (Denver II)
What does the Denver II examine?
Motor, language, and coordination skills in young children
What ages is the Denver II designed for?
Ages 0-6
What does the Denver II consist of and how does it generally work?
125 tasks in four developmental areas
Children are only tested on tasks pertinent to their age and previous ages
What are commonly observed neurological changes in older adults?
Slower reaction time
Slower problem solving
Slower voluntary movement
What changes are not associated with normal aging?
Decreased intelligence, memory, and discrimination
What are the usual causes of neurological deficits in older adults?
Medication Poor nutrition Cardiovascular changes Diabetes Degenerative neurological conditions
What is the first sign of neurological deterioration?
Decreased LOC
What are the two assessment tools associated with level of consciousness?
Glasgow Coma Scale
Full Outline of UnResponsiveness
What three things are monitored with the GCS?
Eye, motor, and verbal responses
The GCS helps to monitor…
Neurological decline
What are the drawbacks of the GCS?
Cannot be used on patients with an endotrachial tube because it requires verbal response
What GCS score is considered good?
15 and above
What GCS scores indicate a serious problem/need for intervention?
8 or below
How does the FOUR differ from the GCS?
It is more comprehensive and looks at eye response, motor response, brainstem reflexes, and respiration’s
What is the main advantage of the FOUR over the GCS?
Can be used on patients with an endotrach tube because it does not rely on verbal responses
A decreasing FOUR score indicates…
Worsening neuro function
What are the aspects of assessing orientation?
Person, place, and time
What items are assessed when looking at mental status and cognitive function?
Behavior Appearance Response to stimuli Speech Memory Communication Judgment
When assessing cognitive function, the nurse wants to know…
The patient’s baseline
What are deep tendon reflexes?
Automatic responses that don’t require brain input
What is the grading scale for deep tendon reflexes?
0-4+
What further assessment should nurse do if patient has altered sensation in an area?
Systematically assess the area to determine the border of the changed area
What does the cerebellum do?
Coordinate muscle movement
Regulate muscle tone
Maintain posture and equilibrium
Proprioception
How would a disorder of motor and cerebellar function manifest?
Pain and problems with movement, gait, and posture
When is a Romberg test most often used practically?
By police to look for intoxication
In the medical field, what does a Romberg test look for?
Cerebellar or vestibular disorder
How is a Romberg test done?
Patient stands with feet together and eyes closed and provider checks for excessive swaying
What characterizes a positive Romberg?
Swaying and moving
A positive Romberg means…
The issue is most likely sensory
A negative Romberg most likely means…
The issue is cerebellar
What are some possible causes of abnormal LOC?
Trauma
Neurological disorder
Hypoxia
Chemical substances
What is one of the earliest indicators of increased intracranial pressure?
Change in level of arousal
When determining orientation, which measure remains intact the longest?
The year
In a hospital setting, what might impact a patient’s orientation?
Medication
Stress
Constant lights, noise, and people
Altered sleep schedule
A hospitalized patient not getting enough sleep can lead to…
Hospital psychosis and delirium
Hospital delirium is considered…
A medical emergency
What are some prevention measures for hospital delirium?
Constantly reorient patient to time and situation
Try to maintain sleep/wake cycle
What are anticipated versus abnormal findings in older adult memory?
Loss of immediate short term memory is more common (though not “normal”). Loss of long term memory is abnormal and may indicate neurological problems
What could abnormal findings in thought process, abstract thinking, or judgment indicate?
Dementia Psychosis Alcohol Drugs Delirium Mental retardation
Describe reflexes in older adults
Might not be as strong or fast, but should still be present
What five deep tendon reflexes are assessed?
Biceps Triceps Brachioradialis Patellar Achilles
How would nurse assess tonic neck reflex and what would a normal finding in an infant be?
Turn the head to one side
The body on that side should extend, and flex on the other side
How does a nurse test for babinski refllex?
Stroke the sole of the foot in an arc from the lateral heel across the ball of the foot
What is a positive babinski?
Toes unfurling/fanning
Where would one expect to get a positive babinski?
Children under the age of two
What could a positive babinski indicate in someone over the age of two?
Intoxication
Upper motor neuron disease
What did Piaget term the infancy stage? Why?
Sensorimotor stage
Infant is developing coordination and solves problems by sensory systems
What is a key attribute of those in the preoperational stage?
Egocentricism
What did Piaget term the stage from 2-7 years old?
Preoperational stage
What is one main cognitive connection/skill learned by those in the preoperational stage?
Object permanence
What did Piaget term the stage between 7 and 11 years of age?
Formal operations stage
What cognitive processes begin in the formal operations stage?
Introspection
Idealism
Reemergence of egocentricism
groundwork being laid for abstract thinking
What did Piaget term the stage that begins at 12 and continues through adulthood?
Concrete operations stage
What characterizes the concrete operations stage?
Being able to think realistically and objectively
Being able to analyze all aspects of a situation and form a hypothesis
What are some possible causes of cognitive problems in older adults
Electrolyte imbalance
Diabetic ketoacidosis
Hypoxia
What are the symptoms of dementia?
Language difficulty
Problems with language
Problems with object recognition
Problems with planning
What does PERRLA stand for?
Pupils Equal Round Reactive to Light Accommodation
What will a focused neuro exam look at?
Level of consciousness Sensation Pain Strength **only assess problem areas/complaints, don’t over assess**
Solute
Solid substance that dissolves in fluid
Electrolyte
Substance that develops an electrical charge when dissolved in water
ICF
Intracellular fluid, fluid found in cells
ECF
Extracellular fluid: fluid found outside of cells (either interstitial or intravascular)
Cation
Positively charged electrolyte
Anion
Negatively charged electrolyte
What are the major electrolytes in the ICF?
Potassium and magnesium
What are the major electrolytes in the ECF?
Sodium, chloride, bicarbonate, and albumin
Osmosis
Movement of water from an area of higher concentration to an area of lower concentration
Diffusion
Movement of molecules from an area of higher concentration to lower
Filtration
Water and particles moving together from an area of higher pressure to an area of lower pressure
Active transport
Movement of water and/or particles against a concentration gradient (requires energy)
What are the major functions of sodium?
Maintenance of BP and blood volume
Transmission of nerve impulses
Fluid balance
What are the functions of potassium in the body?
Normal function of nerves and muscles, especially the heart
Cellular metabolism
How does potassium relate to blood pressure?
Potassium deficiency may be linked to higher BP
What is the function of calcium in the body?
Bone health
Neuromuscular and cardiac function
Blood clotting
What does magnesium do in the body?
Aids in over 300 biochemical reactions
Bone strength
Nerve and muscle function
What is the function of chloride in the body?
Helps maintain fluid balance between ICF and ECF
What is the most abundant ECF anion?
Chloride
What is the function of phosphate in the body?
Bone and teeth formation
Bone and teeth health
What is the function of bicarbonate in the body?
Maintain acid/base balance
What are the risks with not consuming enough potassium?
Higher BP
Kidney stones
Risk of bone turnover
How long can renal mechanisms take to take effect in the body for balancing pH?
Up to three days
Define deficient fluid volume
Proportional loss of fluid and electrolytes from the extracellular space
Define excess fluid volume
Excessive retention of sodium and water in the extracellular space
How much of a loss of body fluid must occur to be considered significant?
5% loss of body weight in fluid
Losing how much body weight as fluids is usually fatal?
15%
What are the signs and symptoms of deficient fluid volume?
Thirst Increased heart rate Weak and rapid pulse Orthostatic hypotension Dry skin/decreased turgor Flat neck veins Decreased urine Increased temperature
What are the signs and symptoms of excess fluid volume?
High BP Edema Bounding pulse Lung crackles Distended neck veins
What are some physical assessment components that can be used to monitor fluids, electrolytes, and acid/base balance?
Skin Mucous membranes Cardiovascular changes Respiratory changes Vital signs Daily weights Intake and output Capillary refill
What are some things that should be evaluated when doing a nursing history focused on fluids and electrolytes?
Medical history Current concerns Food/fluid intake Elimination Medications Lifestyle
What are some laboratory tests to monitor fluid, electrolyte, and acid/base balance?
CBC Serum electrolytes Serum osmolality Urine osmolality Urinalysis
What are some strategies to prevent fluid and electrolyte imbalance?
Limit sodium and increase potassium and calcium in diet
Give electrolyte supplements if necessary
Facilitate fluid intake and restriction as needed
Give paraenteral replacement of fluid and electrolytes as needed
Identify meds causing imbalances
What is an electrolyte related risk with the diuretic Lasix?
It removes potassium as well
How much of body weight does ICF account for?
40%
How much of body weight does ECF account for?
20%
Which electrolyte has an inverse relationship with calcium?
Phosphorus
What are general recommendations for total fluid intake for men and women?
Men: 3700 mL/day
Women: 2700 mL/day
Bicarbonate is regulated by…
The kidneys
What is the principle buffer system in the body?
The carbonic acid and sodium bicarbonate system
How does a buffer system work?
A weak acid and a weak base absorbing or releasing hydrogen ions from strong acids and bases as necessary. They do this to keep the strong acids and bases from altering body pH
How do the lungs compensate when serum pH is too acidic?
Rapid, deep breathing (to get CO2 out of body)
When the serum pH is too alkaline, how do the lungs compensate?
Shallow respirations (to conserve CO2)
What is third spacing?
Shifting of fluid from the intravascular to the interstitial space
What are some risk factors for fluid imbalance?
Depression Burns Confusion Fever Hyperventilation Diarrhea Pneumonia Medical processes
What happens with SIADH?
Too much ADH is produced, leading to over hydration and possible hyponatremia (because water will outweigh the salt)
What are normal serum sodium values?
Between 135 and 145 mEq/L
What are normal serum magnesium values?
Between 1.5 and 2.5 mEq/L
What are normal serum potassium values?
Between 3.5 and 5.0 mEq/L
NG suctioning puts a patient at risk for what fluid and electrolyte issues?
Dehydration and hypomagnesia
When a COPD patient is having difficulty breathing, a nurse should…
Have them do pursed lip breathing
DO NOT increase 02, this makes it harder for them!
What are normal serum bicarbonate levels?
20-28 mEq/L
What are some vulnerable subcultures we will be treating in nursing?
Homeless Elderly Mentally ill Poor Physical disabilities
Vulnerable populations have lack of access to what?
Healthcare
What are some examples of non-race based minorities?
Groups like male nurses, single mothers, etc
Define culture
What people have in common. It is all encompassing and provides identity for those in the culture. It is learned, taught, and shared
Define ethnicity
Has members who share the same social and cultural heritage that is passed on from generation to generation
How is race different from ethnicity?
Race is solely based on biological similarities, not on social and cultural factors
Give examples of different “races”
Korean
Northern European
African American
Give examples of different ethnic groups?
Latinos
Hmong
Define socialization
How one learns to be a member of their society
Define acculturation
Assuming the characteristics of the culture
Define cultural assimilation
Taking the essential values, beliefs, and practices of dominant culture
Define cultural conflict
Conflict between guest of a different culture and the culture they are in
Define culture shock
Cultural misunderstanding or surprise, with interpersonal conflict due to highly different methods of doing things
In what ways does culture provide an identity for an individual?
Provides framework for beliefs, habits, food choices, values, and actions
What is an archetype?
Example of a person or a thing that has its basis in facts
What is a stereotype?
A widely held but oversimplified and unsubstantiated belief about all people in a certain cultural or ethnic group
What are six cultural specifics (things particular to a culture) that can affect health and the view on it?
Communication Personal space Time orientation Social organization Beliefs about amount of environmental control Biological variations
How can a nurse use cultural specifics to provide better care?
I can use it to better understand clients beliefs about healthcare and the expected outcomes of healthcare, making care more culturally competent
What types of alternative healthcare are delivered by formally trained practitioners in healthcare settings?
Diet therapy
Reflexology
Chiropractic
What are magico-religious belief systems?
Religious systems that believe in mystical supernatural forces
What are efficacious healthcare practices and how does the nurse respond to them?
Cultural health practices that are helpful to the client, so the nurse can support the patient integrating those practices into their care
What is folk medicine?
Certain beliefs and practices that cultural members follow when sick
Give examples of folk medicine practices
Using herbs Drinking tea Rituals when sick Taking vitamin C Drinking chicken soup
Define cultural competence
Becoming more aware of and sympathetic to other cultures and being able to use that in practice
How does ethnocentric is impede nursing care?
Prevents the nurse from seeing and understanding the patient’s point of view. Also instills a lack of respect for the patient into the nurse-patient relationship
How is discrimination different from prejudice?
Prejudice is the attitude, discrimination is the behavior that results from the prejudice
What does the BALI acronym stand for? (Pertains to cultural competence)
Be aware of your cultural heritage
Appreciate the uniqueness of your client
Learn about the clients culture
Incorporate clients culture and values into care
The most critical aspect to providing culturally competent nursing care is…
Communication
Culturally sensitive nurses have what trait?
Respect for the cultures and ethnicities of the patients they are caring for
True/false: you can ask the patient which cultural group and racial affiliation they identify with?
True! It is culturally competent to not assume that you know automatically and much better to ask
REMEMBER EVERY PERSON IS CULTURALLY UNIQUE
And developing cultural competence is the responsibility of EVERY nurse
Education is the number one way to overcome cultural incompetence!
Ask questions, admit you dont know everything, and provide a safe environment for the patient!
Which cultural theorist had the goal of guiding research to help nurses provide culturally congruent care?
Madeline Leninger
What are the three modes of nursing care actions in Madeline Leninger’s culture theory?
Accommodation
Negotiation
Repatterning/restructuring
What does negotiation mean in leningers theory?
Acknowledging gaps in perspectives on care, and negotiating care to be safe for the patient
When might a nurse need to negotiate culturally?
When traditional or folk practices that a patient has could be harmful to the patient
What is restructuring and repatterning in Leninger’s theory?
Attempting to change my actions or the lifestyle of the client
How can a nurse support a patient trying to repattern their behavior?
Encourage the new healthy behaviors while respecting cultural beliefs and values
Which culture theorists said that cultural competence is gained through teamwork, knowledge, ability, and skills?
Purnell and Paulanka
Which nursing theorists said that becoming culturally competent requires skills, awareness, knowledge, and desire?
Campinha and Bacote
The best way to make sure a patient of another culture understood your teaching is…
Have them do a return demonstration/display of what was taught
What are three methods for determining whether hydration is adequate and urine output is within normal limits?
Specific gravity
Color
Volume measurement of urine
What are common medications to increase the amount of urine voided?
Thiazide
Potassium-sparing
Loop-acting
What types of medications are associated with urinary retention?
Antihistamines
Anticholinergics
Antispasmodics
Tricyclic antidepressants
What are some conditions associated with a high incidence of altered urination?
Being a child or older adult Anxiety and stress Hydration level Activity level Medications Anesthetics Surgeries in the reproductive, urinary, pubic area, vagina, or rectum
What are the key elements of a physical assessment for a client with urination problems?
Examination of kidneys, bladder, urethra, skin around genitals
How does one catch a clean-catch urine specimen?
Clean around urinary meatus
Have patient begin voiding and then start catching mid-stream
Collect 30-60 mL
Remove cup and have patient to finish
What are some nursing activities that promote normal urination patterns?
Provide privacy Assist with positioning Facilitate routines Promotes hydration Assist with hygiene
What is a straight catheter and when is it used?
Single lumen catheter
Used to drain bladder and then is removed immediately
What is a Foley catheter and when is it used?
Double or triple lumen catheter that stays in the patients long term
Why is intermittent catheterization preferred for long term catheterization?
It has a lower infection risk than an indwelling catheter
How often should the urine collection bag be emptied?
At least every 8 hours or sooner if needed
What are some factors that affect bowel elimination?
Developmental stage Personal/cultural factors (such as stress, privacy, or more pressing needs to attend to) Nutrition Hydration Medication Activity levels Surgeries Pregnancy Bowel diversions
What are some factors associated with constipation?
Pregnancy
Stress
Low fiber diet
Being bedridden
What are some factors associated with diarrhea?
Allergies/intolerances
Some medications
Coffee sometimes
What causes gas?
Bacteria fermenting food in the colon
What should you discuss with a patient when performing a nursing history focused on elimination?
Normal elimination pattern and appearance
Medications
Any info about bowel diversions, if applicable
What are some laboratory studies done on feces?
fecal fat
Occult blood
Ova/parasites
What are some things that can give a false positive in occult blood tests?
Diet high in red meat
High vitamin c levels
What physical assessments would you perform on a constipated client?
Abdomen, anus, rectum
Examine stool
Listen for bowel sounds
Look at size/shape/contour of abdomen
What are some independent nursing actions that can promote regular elimination?
Provide privacy
Assist with positioning (as normal a position as possible)
Support healthy food/high fiber and fluid intake
Encourage exercise or do range of motion with bedridden clients
Give laxatives if other interventions fail
What are the different types of enemas?
Cleansing
Retention
Return flow
What does a cleansing enema do?
Promotes removal of feces from the colon with either a hypertonic or hypotonic solution
What is a retention enema?
Enema that is inserted and retained to soften stool and promote elimination
What specifically does an oil retention enema do?
Soften stool
What is a return flow enema?
Saline is instilled and drained several times to relieve distended abdomen
What is a return flow enema also known as?
A Harris Flush
How can the nurse make the patient more comfortable when receiving an enema?
Position patient correctly Assist as needed Help to toilet if possible Explain procedure thoroughly Talk to/distract patient during procedure
What are the major patient care concerns associated with bowel incontinence?
Impaired skin integrity
Embarrassment
Dehydration
What are the elements of a bowel training program?
Plan it with the patient Gradually increase fiber and monitor stool Increase fluid Initiate times for defecation Provide privacy and ample time Have plan if constipation develops
What does a healthy stoma look like?
Deep pink to brick red, shiny, and moist
How can you help a patient adjust to living with a bowel diversion?
Teach about diet modification
Teach about ongoing ostomy care
Help them adjust to its presence
Why is skin care around a stoma so important?
Because skin breakdown can lead to infection, pain, and leakage
What effect do cathartics have on the GI tract?
Promote peristalsis and are stronger than laxatives
What effect do narcotics have on the GI tract?
Decrease GI activity (depress CNS) leading to constipation
What are some common cathartics?
Dulcolax
Ex-lax
Senna
What are some dangers of chronic use of cathartics?
Decrease muscle tone in large intestine and decrease responsiveness to laxatives
What are some common laxatives?
Docusate
Milk of magnesia
Mineral oil
How do laxatives work?
Soften stool by drawing fluids into the bowel
What can overuse of laxatives cause?
Diarrhea
Dehydration
Electrolyte depletion
What is a risk of using mineral oil to relieve constipation?
Decreases the absorption of fat soluble vitamins
What is a medication risk of using laxatives?
They may interfere with the effectiveness of other meds by altering the amount of time they’ll be in the GI tract to be absorbed
How can aspirin change fecal appearance?
Can cause GI bleeding and make stool red or black
How can NSAIDS affect fecal appearance?
Red or black stool (d/t bleeding from GI irritation)
How does iron alter stool appearance?
Makes them black
How do antibiotics change stool appearance and why?
They disrupt normal bacterial flora of the GI tract and make stool grey green (often as diarrhea)
How do antacids change stool appearance?
They cause whitish discoloration/specks
What are some diagnostic procedures for the GI tract?
Colonoscopy
Endoscopy
Sigmoidoscopy
What does general anesthesia do to the GI tract?
Slows or stops peristalsis
What is paralytic ileus?
Temporary (24-48 hour) cessation of GI peristalsis due to manipulation of intestines during surgery
ASSESS FOR BOWEL SOUNDS POST OP
..
How soon should newborns void after birth?
Within 24 hours
How will the urine of newborns look? Why?
Light yellow or clear, because they cannot effectively concentrate it
How common are UTIs in infants?
Very common (second most common infection in this age group)
When does the elimination system reach maturity?
Between ages 5 and 10
What is enuresis?
Involuntary passing of urine
What percentage of 6 year olds struggle with enuresis?
10%
When is nocturnal enuresis considered a problem?
When the child is older than 6 years old
Which age group and gender experiences the most frequent UTIs?
Females from the ages of 15-24
What does pregnancy do to the risk of UTIs?
Increases it
Why do men over 50 have increased urination frequency?
Enlarged prostate gland
By what percentage does total number of nephrons decrease by age 75?
30-50%
How does bladder capacity change in older adults?
Decreases from around 500ml to 250 ml
Which care professionals are allowed to change the ostomy bags?
Only the RN
What are special considerations for 24 hour urine collections?
Must be kept on ice
Must get ALL urine for a 24 hour period
Upon initiation, pt must void, discard that urine, and then collect everything for 24 hours
What are some common antidiarrheal medications?
Imodium
Lomotil
How does the nurse manage fecal impaction?
PREVENTION is the optimal strategy
Determine presence of impaction
Can only do digital removal if presence is confirmed
Enema can be used to soften
How much urine should an infant produce per day? How many diaper changes is this?
15-60 ml/kg
8-10 wet diapers per day
What is stress incontinence?
Urine incontinence upon activities like laughing, sneezing, and coughing
Where should the urine collection bag rest?
Below the level of the bladder but off the floor
Is a doctors order needed for catheterization?
Yes
Is a doctors order needed for a bladder scan?
No, nurse can decide to do independently
What are Kegel exercises?
Pelvic floor muscle exercises
How does the nurse assess fundal height/uterine placement in the mother postpartum?
Put one hand on top of the uterus and one hand below to support, and then you can assess placement
How long does involution of the uterus take?
Around 6 weeks
How much should the fundus go down ever day?
Between one and two cm
What helps with the fundus descending back down?
Uterine contractions
What do you do for a patient with a sub-involution?
Monitor fundal position, lochia, vital signs
Encourage client to breastfeed, ambulate, and void regularly
Lochia rubra
Dark red, bloody, and heavy flow
First 1-3 days after birth
Lochia serosa
Pinkish brown
4-10 days after birth
Lochia alba
Yellowish white/creamy discharge
From 10 days to 3+ weeks after birth
What level of discharge do you want before patient leaves hospital?
Scant or light (4” or less)
What is one way to determine whether a discharged clot is dangerous or okay?
If it cuts easily, its okay. If its tough and membranous, it signals a problem
What is the difference between a laceration and an episiotomy?
Laceration is a tear that occurs on its own during birth
Episiotomy is an incision made by the doctor during delivery
What kind of education will you provide for someone with a laceration or episiotomy?
Cleanse the area after voiding
Blot the area
Clean from front to back
What is one effective treatment for hemorrhoids?
Sitz baths
Why is tearing preferred over an episiotomy?
Because it involves only soft tissue tear, which heals easier than the muscle incision of an episiotomy
What happens to maternal glucose levels postpartum?
They decrease and return to normal
What happens to estrogen and progesterone levels postpartum?
They decrease
Why are hemorrhoids so common during pregnancy and postpartum?
Because the fetus puts pressure on the veins in the perineum, as does giving birth
When will ovulation resume in lactating women? Non-lactating?
Lactating: approximately 6 months but it can happen sooner
Non-lactating: usually 7-9 weeks
What should lactating and non-lactating women be taught regarding contraceptives?
Lactating women should start contraceptives after milk production is established (at around 6 weeks).
Non-lactating women should start them earlier, because ovulation can occur after just one month
When does urinary function return to normal postpartum?
5-7 days but will take up to a month to be completely normal
Why should a woman empty her bladder after delivery?
To prevent hemorrhage
What happens if the bladder doesnt empty properly in a postpartum woman?
It can displace the uterus and prevent proper uterine involution
Will milk still come in if a woman decides not to breastfeed?
Yes
What are some interventions that can be done for the non-breastfeeding woman when her milk comes in?
Use breast binders, very supportive bras, and ice. Do not support/aid milk expression
What is colostrum and for how long is it present?
It is the early milk-like substance that is produced until the milk comes in. Usually present until 72-96 hours after delivery
What is engorgement and what are some comfort nursing interventions?
Fullness and pain in the breasts
Nurse can administer ice, teach breast care, and promote frequent feedings
What are likely infection areas for postpartum mothers?
Uterus
Breasts
Urinary tract
When is RhoGAM given?
When an Rh- mother gives birth to an Rh+ baby, to prevent the mother from developing antibodies to Rh+ blood in future pregnancies
How can the nurse promote mother-baby bonding?
Delay unnecessary procedures in the first hour after birth so mother and baby can have that time together
Encourage breastfeeding
Skin to skin contact
What are benefits of breastfeeding for the baby?
Excellent source of all needed nutrients
Maternal antibodies
Reduced disease and obesity risk for breastfed children
Reduced infant mortality
What are benefits of breastfeeding for the mother?
Reduced mortality
Decreased postpartum bleeding
Promotes healthy weight loss
What does “baby friendly” hospital status mean?
It means the hospital meets a set of criteria to support breastfeeding and parent-child bonding
How does a nurse assess LATCH?
Assess to see if infant’s mouth is over the nipple, areola, and breast with a seal between the mouth and the nipple
What are the four most common breastfeeding holds?
Football
Modified cradle
Across lap
Side-lying
What are feeding cues that a mother can watch for from her infant?
Firm tugging without pain
Audible swallowing
Round, non-dimpled cheeks
Jaw gliding smoothly
What is a normal respiration rate for a newborn?
30-60 per minute
What is a normal heart rate for a newborn?
110-160 BPM
Where do you take a newborn’s temperature?
Axilla
When doing newborn vitals, which should be assessed first?
Respiration and heart rate
What is the normal range for blood pressure in newborns?
60-80 systolic
40-50 diastolic
What is caput?
Swelling of the soft tissues of the scalp (filling up with non-blood fluid)
What is cephalhematoma?
Blood between the periosteum and skull bones (medical emergency)
What can newborns see at birth?
Things 8-12 inches from their face
What can newborns hear?
Almost as much as adults
What might it indicate if the infant’s nostrils are flaring with each breath?
Possible nasal blockage
What are retractions? Why are they concerning?
The area between the ribs and the neck sinking in during infant’s inhalations.
Sign of difficulty breathing
What is the normal vessel content of the umbilical cord?
2 arteries and one vein
What is pseudomenses?
Blood tinged vaginal discharge seen in some newborn females due to estrogen levels (very normal)
When should an infant’s first bowel movement occur?
12-24 hours after birth
What does breast milk stool look like?
Yellow/golden and pasty, less smelly
What does formula stool look like?
Yellow brown, with a firmer consistency and stronger smell
What will stool with bilirubin present look like?
Brown (will be pale without)
What is a normal voiding pattern for newborns?
2-6 times a day on the first and second days
6-8 times per day after that
Lanugo
Fine downy hair
Milia
White spots on newborn’s skin
Vernix caseosa
Protective, thick, cheesy skin covering
Will premature babies have more or less vernix?
More do not take off
Stork bites
Flat pink or red marks on the neck or face (normal birthmarks)
Erythema toxicum
Pink rash appearing in the first 3 weeks of life. Very mild allergic reaction that is fairly normal
Mongolian spots
Spots of pigmentation on the back and butt that are very common on babies of color
Port wine stains
Purple/red capillary angiomas common on infants faces. Not treatable and dont usually go away
What are some health promotion activities for newborns?
Promote breastfeeding
Newborn screenings
Administer medications and vaccinations
What are the normal newborn screenings?
Universal newborn screening
Hearing
Bilirubin
Congenital heart defect screening
Why is erythromycin given to infants and in what form?
Given as eye drops to prevent conjunctivitis and blindness from potential bacteria encountered in birth canal
What are the main nursing activities in the first three days postpartum?
Prevent complications Promote breastfeeding Support comfort levels Family bonding Education about self care, infant care, and home care
What is BUBBLE used for?
Postpartum assessment
What does BUBBLE stand for?
Breasts Uterus Bladder Bowel Lochia Episiotomy/perineum
What is the CE added on to BUBBLE?
Calves (for DVT)
Emotions
How much extra fluid does the body gain during pregnancy?
1500 cc
What are some common/good postpartum nursing interventions?
Prevent bleeding and infection Monitor vitals and labs Monitor for bladder distension Promote early ambulation and vaccination Promote rest, comfort, breast care, exercise, and nutrition
How big is a newborn baby’s stomach?
About the size of a walnut
How much milk do newborns need at a feeding?
Only a teaspoon
How often should breastfed newborns feed and for how long?
Every 2-3 hours for 10-20 minutes
How often should bottle fed infants feed?
Every 3-4 hours
Why do bottle fed infants have to be burped?
Because air gets in the stomach as well (no seal like with breastfeeding)
What are common care tactics for episiotomys?
Sitz baths
Keep it dry
Use lidocaine gel if prescribed
What is the usual time period for discharge from the hospital for mother and baby?
48 hours for a vaginal delivery
96 hours for a c-section
What should be included in a newborn assessment history?
Date/time of birth Gestational age Method of birth Sex Apgar scores Void or stool issues during birth
What five things are measured in APGAR scoring?
Activity (muscle tone) Pulse Grimace (reflex) Appearance (skin color) Respirations
What would get an infant a 2 in the pulse area?
HR over 100
What would get the infant a 2 in respirations?
A strong, loud cry
What is acrocyanosis?
Blue coloration of the extremities. Common in infants right after birth
What are some contributing factors to jaundice?
Immature liver
Excessive hemoglobin in body
Not passing urine yet
Not feeding well
Why is feeding a proper treatment for jaundiced infants? What does it prevent?
Bilirubin then binds to the protein of food and doesnt reach the brain and bind there, which can cause seizures
What could it mean if the newborn does not have two arteries and one vein in the umbilical cord?
Kidney issues
What might uneven gluteal folds or gluteal muscles indicate?
Dislocated hip
Controlling thermoregulation in newborns prevents what two issues?
Cold stress and hypoglycemia
What are some staples of umbilical cord area care?
Keep it dry
Wash with soap and water
Watch for infection
What is the first period of reactivity in the infant?
The first hour after birth, infant is alert and responds to mother. Try to promote first breastfeeding in this time!
What is the second period of transition/reactivity in the infant?
From 1-4 hours after birth. Infant is usually asleep
When is the third period of transition/reactivity?
After the fifth hour, and will last for 2-8 hours
What are the four components of the sensory experience?
Stimulus
Reception
Perception
Arousal mechanism
What does a receptor do?
Converts a stimulus into a nerve impulse and transmits the impulse to the CNS via sensory neurons
The process of receiving a stimuli is called
Reception
The ability to interpret sensory impulses is
Perception
What do nociceptors sense?
Pain
What do chemoreceptors sense?
Chemical changes in the body
How does perception relate to/impact our senses?
Perception allows us to use our senses and make sense of stimuli
How much sensory information does the brain discard?
99%
What is the RAS?
Reticular activating system
What does the RAS do?
Controls consciousness and alertness
How does the RAS control consciousness and alertness?
It coordinates brain regions to keep us awake, attentive, and observant. It keeps us sensing and responding to our environment
When measuring levels/effectiveness of sedation, what is being looked at?
The RAS, and whether its currently active or not
Is level of stimuli necessary to maintain arousal the same for everyone?
No it varies from person to person and can also vary for each person depending on the environment
Response to a stimulus is influenced by what factors?
Intensity
Contrast to other stimuli
Adaptation
Previous experience
What are some other factors that can influence how we do or don’t respond to stimuli?
Illness Injury Medication Stress Personality Lifestyle
What are some sensory/perceptual characteristics of newborns?
Less acute vision Very acute hearing at low frequencies Reactive to odors Prefer sweet to sour tastes Very keen sense of touch
What are some sensory/perceptual characteristics of infants?
Need sensory stimulation
Can discriminate sounds and observe light/color/contrast
What are some sensory and perceptual characteristics and developments in children and adolescents?
Improved vision Full depth perception develops Balance improves Hearing fully developed Increased sensory stimulation due to increased socializing
What are some sensory/perceptual characteristics of older adults?
Slower reflexes
Less response to stimuli
Decreased vision/hearing
Decreased sense of touch
How does culture impact sensory-perceptual status?
It affects how much stimulation one is comfortable with (example: eye contact, personal space, touch)
What is sensoristasis?
A state of optimal sensory arousal
What is sensory deprivation?
depression of the RAS due to lack of meaningful stimuli
What does it mean to fill in the sensory gap?
Becoming overly sensitive/reactive to remaining stimuli when experiencing sensory deprivation
What are some outcomes of filling in the sensory gap?
Distress
Problems with perception, cognition, and emotion
What is the nurses main goal with sensory deprivation?
Prevention
What increases the risk of sensory deprivation?
Impaired sensory reception (sensory losses, neurological injury, dementia, etc) Restricted mobility Inability to transmit or process stimuli Boring environment Inability to interpret cultural cues
What are some interventions for the patient with sensory deprivation?
Provide stimuli
Support senses
Continual orientation
Use of comforting touch
What are signs ands symptoms of sensory deprivation?
Irritation Confusion Reduced attention span Drowsiness Preoccupation with somatic complaints Delusions Hallucinations Reduced problem solving
What is sensory overload?
When environmental or internal stimuli are more than the patient can tolerate or effectively process
What are some signs and symptoms of sensory overload?
Irritability Confusion Poor attention span Decreased problem solving Muscle tension Anxiety Difficulty concentrating Restlessness Disorientation
What are some interventions for sensory overload?
Minimize stimuli
Provide rest
Infrequent visitors (especially for those with brain injuries)
From what do sensory deficits stem?
Impaired reception, perception, or both
Which sensory deficits are nurses most likely to encounter?
Impaired vision/hearing
What area of the brain in closely associated with vision?
Occipital region
Which area of the brain is most closely associated with hearing?
Occipital region
What tastes can be detected by the tongue and which areas sense these tastes?
Sweet and salty (tip)
Sour (lateral)
Bitter (posterior and soft palate)
What is one of the most common causes of impaired taste? What causes it?
Xerostomia, which is excessive dry mouth often caused by medications
What are some results when someone loses the sense of smell?
Food wont taste the same, leading to potential nutritional deficits
Inability to smell rotten food or smells associated with danger
How can a nurse make therapeutic use of a patients sense of smell?
Aromatherapy
What is two point discrimination?
Ability to perceive two points of pressure that are close but not touching
Where is two point discrimination the most sensitive? Least?
Most sensitive: lips and fingertips
Least sensitive: torso
Where in the brain does conscious muscle sense stem from?
Parietal lobe
Where in the brain does unconscious muscle sense stem from?
Cerebellum
What is the connection between optimal sensory function and health screening?
Many sensory problems are related to other healthcare issues, and need to be identified and treated early to preserve sensory function
What are some interventions the nurse can use for a patient with a visual impairment?
Glasses Sufficient light Large print books Keep important objects close Evaluate and respect independence
What are some interventions for a patient with impaired hearing?
Hearing aid care Closed caption TV Promoting environmental safety Assessing for isolation issues Inspect ear canals Quiet areas for communication
What are some interventions for the confused patient?
Assess orientation and continually reorient them Provide safe environment Communicate clearly and slowly Limit choices, but do give choices Make them feel secure
What are some interventions for the unconscious client?
Continually orient to reality
Safety measures
Attend to body systems and sensory needs just like you would if they were conscious
Can the Glasgow coma scale help determine nursing actions/care for a patient with altered LOC?
Yes
